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Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to follow their Grievance Policy and Procedure to ensure prompt resolution for one (1) of ten (10) sampled patients, Patient #1.

The findings include:

Review of facility's policy, Patient Complaint/Grievance Process, dated June 2016, revealed the purpose of the policy was to provide a process to review, investigate, and resolve a patient's/patient's representative's complaint or grievance within a reasonable time frame. In addition, to provide a quality improvement approach to evaluate the effectiveness of the complaint and grievance process and to identify and implement improvement as indicated. Once action had been taken, the facility assured the complaining party was aware of the investigation results and actions taken. The Chief Executive Officer's (CEO) obligation was to oversee the process by holding managers and directors accountable for conducting a thorough, accurate, and timely investigation, initiating prompt intervention, and escalating unresolved issues. The CEO was to call the complainant to discuss the results of the investigation and the actions taken to resolve the grievance. The CEO was to ask the complainant if they considered the matter resolved and when a final resolution was obtained, ensure a response letter was sent. The CEO could designate and direct a representative to prepare the letter or contact the complainant when resolving the grievance.

Review of Patient #1's clinical record revealed the facility admitted the patient on 01/13/17, with diagnoses of Acute Respiratory Failure, Clostridium Difficile Infection, and End Stage Renal Disease.

Review of a facility's Grievance response letter, dated 03/29/17, revealed the facility had received a complaint from Patient #1's spouse, which concerned the cleanliness of the patient's room and staff not changing tubing when needed. The facility responded by addressing the grievance response letter to Patient #1 and the facility apologized for the experience Patient #1 had and were serious about maintaining the improvements Patient #1's feedback had initiated. Having taken action, the facility considered the matter closed. If the problem occurred again, Patient #1 was encouraged to let the facility know as soon as possible.

Review of a Patient and Family Complaint/Grievance Report Form, dated 03/28/17, revealed Patient #1's Spouse complained Patient #1's room was never cleaned and the tubing, used with the breathing machine, was not changed when needed. The immediate actions taken at the time was the facility apologized for the issues; however, no evidence was provided during the survey revealing the patient's room was cleaned immediately after the complaint was made. Under the Department Manager/Supervisor Review section, it stated the Environmental Services Supervisor would coach housekeeping staff on properly cleaning rooms and nursing staff would be coach on changing tubing properly. At the bottom of the form, there was an area to check that indicated follow-up communication with the complainant occurred to determine if the issue was resolved; however, the area was blank.

Observation of Patient #1, on 06/07/17 at 10:00 AM, revealed the patient was dressed in a hospital gown, lying in bed, connected to a breathing machine, and his/her eyes were closed. The patient's bathroom floor had a dry black substance in front of the toilet and an orange/brown substance around the base of the toilet. The floor around the patient's bed contained a dark brown/black sticky substance. There was a white and orange substance on the base of the intravenous pole. There was dirt and debris behind the head of the bed and in the corners of the room. Patient #1's suction tip and tubing was on the floor beside the bed, along with an empty box of facial tissue. Continued observation at 11:00 AM, revealed staff had changed the suction tip, but not the tubing.

Observation and interview with Housekeeper #1, on 06/07/17 at 12:10 PM, revealed she was in another area of the building, which was not a part of the hospital, and stated she had heard Patient #1's daughter had a problem that morning, 06/07/17, with the cleanliness of the patient's room. Housekeeper #1 stated staff had requested she clean the room so she swept, mopped, and dusted the room. Upon return to the Patient #1's room with the Surveyor for observation, Housekeeper #1 stated there was a black and orange substance on the floor. According to Housekeeper #1, she had mopped the floor and did not know why the substance was still there. According to Housekeeper #1, it was her normal daily routine to clean Patient #1's room and that all rooms received the same daily cleaning. She stated she had not received coaching on properly cleaning Patient #1's room. She revealed her supervisor did spot checks on her work but as far as she knew, daily audits of Patient #1's room to determine if staff cleaned it appropriately were not performed.

Interview with Patient #1's Spouse, on 06/07/17 at 7:19 PM, revealed the Spouse had not received a grievance response letter from the facility and did not consider the grievance resolved. The Spouse stated the issues regarding the cleanliness of the room remained as the facility had not cleaned the floor properly and the issue with the tubing still occurred.

Interview with the Housekeeping Manager, on 06/08/17 at 8:50 AM, revealed the supervisory staff did not recall getting information regarding Patient #1's grievance. The Housekeeping Manager stated there was no evidence that the facility provided coaching to the housekeeping staff on how to clean patient rooms properly. The Manager stated to her knowledge, the facility had not developed an action plan to ensure the cleaning issues remained resolved.

Interview with the Infection Preventionist (IP), on 06/07/17 at 3:10 PM, revealed Patient #1's family was agitated with staff and housekeeping. She stated a month or two (2) ago, a family member made her aware of the issue with the tubing and she spoke with the nurse on duty at the time; however, she could not recall the day or the name of the nurse. The IP stated she rounded on Patient #1 daily due to Patient #1's infection control issues and because she had identified cleanliness issues with the room. She believed there was an issue with the contracted housekeeping staff not providing services to maintain a clean environment. According to the IP, the family's concerns were discussed with the Chief Executive Officer (CEO) and she believed the CEO had addressed the issues. She stated no one directed her to perform the grievance follow-up process related to whether the complainant considered the issues resolved.

Interview with the CEO, on 06/07/17 at 1:55 PM, revealed during a meeting with Patient #1's Spouse, on 03/29/17, the facility became aware of the grievance regarding the uncleanliness of Patient #1's room and the tubing not changed as needed. She stated according to the documented evidence, the facility only apologized to the Spouse and did not ensure actions were taken to resolve the issues. The CEO stated she thought the IP had followed up with the complainant regarding whether they considered the grievance resolved or not. The CEO revealed she did not follow up with the complainant and believed the issues were resolved. She stated as far as she knew, an action plan to ensure the issues did not reoccur was not developed. She stated following policy and procedures ensured patient needs were met and that had not occurred.

Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to maintain a sanitary physical environment to prevent the spread of infection for three (3) of ten (10) sampled patients, Patient #1, #2, and #6. Observations revealed a black sticky substance on floors, an orange/brown substance around a toilet base, and suction tubing was on the floor. In addition, three (3) other patient rooms had debris on the floors, garbage cans overflowing with trash, and intravenous pole bases soiled with a brown/white substance.

The findings include:

Review of the facility's policy, Infection Control Program, dated February 2014, revealed an Infection Control Program was designed and implemented to identify and reduce the risk of acquiring and transmitting infections among patients, staff, physicians, licensed independent practitioners, volunteers, students, and visitors. It was maintained to provide a safe, sanitary, and comfortable environment that involved each department. The infection prevention and control program included processes to minimize healthcare associated infection through an organization-wide program. These processes included but were not limited to the: ongoing identification of risks associated with the transmission of infectious agents, establishing priorities and goals for preventing the development of healthcare associated infections within the hospital, achieving an appropriate system of communication within the healthcare system to deliver information about infection prevention control and risks to patients, visitors, and staff, and developing and implementing necessary policies and procedures to prevent the spread of infections that included promoting consistent adherence to Standard Precaution and other infection control practices. A surveillance process would be in place to monitor for exposure to infectious disease, prevent transmission of infectious disease, identify opportunities for improvement, and identify trends indicating the increase in infections or outbreaks. The essential elements of a surveillance system included infection surveys and data collection, environmental surveillance rounds throughout the facility, identification of patients at risk, and processes or outcomes surveillance.

Review of the facility's Housekeeping Contract, not dated, revealed the contracted company shall be responsible for all equipment, staffing, supplies, and administrative support to provide housekeeping and linen services in accordance with all applicable standards. The contracted company shall provide housekeeping and linen services no less frequently than every day and when requested, to include dusting, vacuuming, cleaning of bathrooms, restocking of linen closets, removal of general trash and hazardous toxic or infectious waste created by hospital activities, on a daily basis. The company would assist in the cleanup of spills and other minor accidents promptly upon request. The company shall monitor quality control and conduct periodic quality control checks.

Review of the facility's Standard Housekeeping Work Activity Sheet, not dated, revealed the housekeeper should pull trash and straighten up each patients room to always keep it clean. The door handles, light switches, room furniture, over bed tables, nurse call bells, phone cords, bed handrails, sinks, toilets, and dispensers should be cleaned. The rooms should be dust mopped and then wet mopped. Continued review of the Activity Sheet revealed the cleaning of discharged patient rooms took priority. The form made no delineation of which department was responsible for cleaning patient equipment or intravenous poles.

Observation of Patient #1's room, on 06/07/17 at 10:00 AM, 11:00 AM, and 12:10 PM, revealed the bathroom floor had a dry black substance in front of the toilet and an orange/brown substance around the base of the toilet. The floor around the patient's bed contained a dark brown/black sticky substance. There was a white and orange substance on the base of the intravenous (IV) pole. There was dirt and debris behind the head of the bed and in the corners of the room. Patient #1's suction tip and tubing was on the floor beside the bed, along with an empty box of facial tissue. The observation at 11:00 AM, revealed the suction tip was changed but not the tubing.

Interview with Patient #1's Spouse, on 06/07/17 at 7:19 PM, revealed the Spouse had complained about the cleanliness of Patient #1's room several times to staff and administration but felt like the facility did not take the concerns seriously. The Spouse stated staff did not clean the floor properly and the tubing used on the patient was on the floor several times and not changed routinely to prevent infection. According to Patient #1's Spouse, there was also feces left on the toilet seat for several days after an aide had emptied the patient's bedpan and the Spouse was concerned about the spread of germs.

Review of the facility's Patient and Family Complaint/Grievance Report Form, dated 03/28/17, revealed Patient #1's Spouse complained the patient's room was never cleaned and the tubing, used with the breathing machine, was not changed when needed. The immediate actions taken at the time was the facility apologized for the issues; however, no evidence was provided during the survey that the patient's room was cleaned immediately after the complaint was made. Under the Department Manager/Supervisor Review section it stated the contracted Environmental Services Supervisor would coach staff on properly cleaning rooms and the nursing staff coached on changing tubing properly.

Observation and interview with Housekeeper #1, on 06/07/17 at 12:10 PM, revealed she was in another area of the building, which was not a part of the hospital, and stated she had finished with her assigned cleaning responsibilities for the hospital and now was onto her next assignment. She stated she heard that Patient #1's daughter had a problem that morning, 06/07/17, with the cleanliness of the room. She stated staff requested she clean the room a little over an hour ago. She stated she swept, mopped, and dusted the room. Housekeeper #1 stated if patient rooms were not properly cleaned, germs could be spread. The Surveyor and Housekeeper #1 returned to Patient #1's room to observe the cleanliness of the room. Housekeeper #1 stated there was a black sticky substance on the floor around the patient's bed and in the bathroom. In addition, she stated an orange/brown substance was on the floor around the base of the toilet. She stated she could not explain why the substances were there after she had mopped the floor.

Interview with Patient #1's Daughter, on 06/07/17 at 12:20 PM, revealed she often had to clean the patient's room because feces was left on the toilet seat and the tables would be sticky with an unknown substance. She stated housekeeping would sweep and mop but never moved furniture to get underneath, until today. She stated Patient #1's Spouse filed a grievance several weeks ago about the cleanliness of the room, but she had not seen an improvement in the quality of housekeeping since the complaint. She stated Patient #1 deserved a clean room.

Interview with the Infection Preventionist (IP), on 06/07/17 at 1:55 PM, revealed she had requested Housekeeper #1 to clean Patient #1's room on 06/07/17, because the family made comments that the room was not clean. She stated she watched the housekeeper begin the cleaning process, but did not stay to observe the cleaning of the floor. She stated housekeeping staff cleaned IV poles and equipment after patients were discharged and nursing staff was responsible while patients were still in the room. According to the IP, she had determined there was a need for re-education regarding the cleaning process after she had audited the cleanliness of a discharge room Housekeeper #3 had completed today, 06/07/17. She revealed she made rounds on the unit, but did not routinely go into patient rooms to observe for repeated cleanliness issues or to talk with patients and families to get their input. She stated she had found rooms not thoroughly cleaned and received complaints from family and patients. The IP stated she had notified the unit's nursing supervisor and the housekeeping supervisor to inform them of the issues. However, she did not believe corrective action was taken on the part of housekeeping to rectify the identified cleaning issues. She stated most of the facility's patient population had an infectious disease, which could be spread if thorough routine cleaning did not occur.

Interview with the Housekeeping Manager, on 06/07/17 at 1:30 PM and 06/08/17 at 8:50 AM, revealed she was not aware of Patient #1's family's grievance concerning the room not being cleaned thoroughly or that there were other cleaning issues identified on the unit. She stated random audits were performed to check the quality of work the housekeepers had completed but there was no documented evidence Patient #1's room had been audited. She revealed it was identified today, 06/07/17, that Housekeepers needed coaching on the proper way to clean a discharge room. She stated up until now, no plans had been made to address housekeeping issues and the Administrator had not contacted them regarding cleanliness issues or the need to coach their staff. According to the Housekeeping Manager, her observations of the patient rooms on 06/07/17, revealed there were issues with the quality of housekeeping services and if staff did not clean the unit properly, germs could spread and people could get sick.

Observation of Patient #2's room, on 06/07/17 at 8:55 AM, 10:11 AM, and 1:58 PM, revealed the floor was black and sticky with debris littering the floor. An IV pole beside the head of the bed had an unknown brown and white substance on the base. The bathroom toilet had a brown and black substance on the rim and the bathroom counter was stained with white rings.

Interview with Patient #2's Responsible Party (RP), on 06/07/17 at 8:55 AM and 10:10 AM, revealed the housekeepers partially swept and mopped the room and did not move furniture or equipment to get underneath. She stated housekeepers did not wipe down the bed rails, over bed table, or end tables, and believed feces was on the toilet seat. She was not impressed with how the housekeepers cleaned the room and felt it was necessary to bring her own disinfectant wipes from home to clean the tables and bed rails. Patient #2's RP revealed she had not reported the housekeeping concerns to staff in order for it to be addressed because staff was busy. According to the Patient #2's RP, the patient was in isolation for an infection and it was important for surfaces to be cleaned to help prevent the spread of germs.

Observation of Patient #6, on 06/07/17 at 9:02 AM, revealed the patient was receiving a breathing treatment while sitting up in bed. The room had dirt and debris on the floor. Continued observations at 10:10 AM, 12:30 PM, and 2:30 PM, revealed the dirt and debris remained on the floor.

Interview with Patient #6, on 06/07/17 at 10:10 AM, revealed housekeeping cleaned the room daily; however, they could do a better job. Patient #6 stated housekeeping was very busy and he/she did not want to complain.

Observation of patient room 432, on 06/07/17 at 8:56 AM, 10:12 AM, and 1:56 PM, revealed the room had dirt and debris in various areas on the floor and the garbage can was over flowing with trash.

Observation of patient room 433, on 06/07/17 at 8:59 AM, 10:13 AM, and 1:55 PM, revealed the room had dirt and debris in various areas on the floor and the garbage can was full of trash.

Observation of patient room 435, on 06/07/17 at 9:08 AM, 10:13 AM, and 1:54 PM, revealed the room had dirt and debris in various areas on the floor.

Interview with Housekeeper #3, on 06/07/17 at 12:50 PM, revealed he still had several patient rooms to clean because he was called to clean a discharge room. He stated it took forty-five (45) minutes to one (1) hour of his day to clean a discharge room and he could have one (1) each day. Housekeeper #3 stated he worked until 3:30 PM and would attempt to clean the rest of rooms on his list and after 3:30 PM, no housekeeping staff was on duty and it was the responsibility of the nursing staff to clean rooms if a need arose. He revealed he did not clean IV poles or wipe down equipment unless it was in a room where a patient had been discharged. According to Housekeeper #3, most of the patients on the unit were in isolation and if rooms were not cleaned, germs could spread to staff, patients, and visitors.

Interview with Certified Nursing Assistant (CNA) #1, on 06/08/17 at 9:55 AM, revealed she was not responsible for cleaning IV poles; it was the nurses' responsibility. She stated housekeeping cleaned patient rooms but was not sure how often they cleaned each room. CNA #1 stated some patient rooms were cleaner than others. CNA #1 revealed she had not received any coaching on her responsibility regarding cleaning a patient room. She stated it was common sense that if staff made a mess providing care then that same staff should be the one to clean it up. CNA #1 had seen feces left on toilets and not cleaned by the previous staff member providing care to a patient. She stated she was not sure which housekeeping tasks were the responsibility of housekeeping or what nursing staff was supposed to clean. According to CNA #1, she tried to wipe things down as much as she could, time permitting, because she did not want to catch or spread an infectious disease.

Interview with Registered Nurse (RN) #2, on 06/07/17 at 8:35 AM, revealed patient rooms were not cleaned to her expectation. Patient floors contained a black substance and IV pole bases were dirty from tube feeding dripping on them. She stated she had seen dried feces on toilets for several days. RN #2 stated she did not mop floors or clean toilets; it was housekeeping's responsibility and it was the responsibility of housekeeping to clean the IV poles and patient equipment. RN #2 revealed she received complaints from patients and families about room cleanliness and would tell housekeeping staff the room needed to be re-cleaned; however, she felt no changes were made to improve the housekeeping quality. According to RN #2, if rooms were not consistently cleaned, cross contamination could happen and patients, families, and staff could get sick.

Continued interview with the Housekeeping Manager, on 06/07/17 at 1:30 PM and 06/08/17 at 8:50 AM, revealed the thirty (30) bed unit was staffed with one and one half (1 ½) housekeepers during an eight (8) hour shift from 7:00 AM until 3:30 PM, even though it was determined two (2) housekeepers were needed to complete the daily required routine cleaning, without taking any breaks. The determination also did not include the time it took to terminal clean a discharged patient room. She stated housekeepers were responsible for cleaning all thirty (30) patient rooms, the waiting room, nurses' stations, employee and visitor bathrooms, linen rooms, medication rooms, clean and dirty utility rooms, offices, pharmacy, therapy rooms, and the kitchen areas in the eight (8) hour time frame. However, they were not responsible for cleaning IV poles or equipment until the patient was discharged. She stated housekeeping staff was not scheduled to work on the unit after 3:30 PM, so it was nursing staff's responsibility after 3:30 PM to clean if issues arose or it would have to wait until the next day. According to the Housekeeping Manager, maintaining a clean environment helped prevent the spread of infection and if not done properly, staff, patients, and visitors could contract an infectious disease.

Interview with the Chief Executive Officer (CEO), on 06/07/17 at 1:55 PM, revealed she was on the unit each day and depended on the Infection Preventionist to monitor for infection control issues. She stated leaders conducted rounds on patients seeking negative comments so they could improve patient satisfaction. No identified housekeeping issues had caused her to develop, or direct someone to develop, a plan of action to address the quality of housekeeping or prevent the spread of infectious diseases on the unit. The CEO stated she had spoken to the contracted housekeeping management staff about concerns in the past, but had no evidence of follow up or audits to ensure infection control practices related to housekeeping were put in place. According to the CEO, nursing staff was responsible for cleaning the patient's equipment and IV poles and keep the room clean from debris; however, she had not monitored for this or determined if all staff was knowledgeable of the expectation. She stated it was important for infection control and patient satisfaction that patient rooms and the unit were cleaned properly and routinely. She stated if patient rooms were not cleaned properly, infections could be spread to patients, staff, and visitors.