HospitalInspections.org

Based on observation, interview and policy review, the facility failed to ensure a sanitary environment. This has the potential to affect all patients receiving services at the facility. The facility census was 139.

Findings include:

1. During tour of units K2, K3, and K8 on 09/01/20 at 8:45 AM, the following was observed:

In the dining room of K2, there were mouse droppings and a thick brownish residue inside the lower cabinet. Mouse droppings were under the microwave located above the sink. Sticky mouse traps were in the sink area. Splatter and residue was on the walls and kick boards in the dining room. Some appeared to be red sauce, no breakfast items appeared to have any red sauce. Staff A verified that no red sauce was served with breakfast at the time of the observation. Observation in patient room K2-16 revealed a spider web located under the sink area, the walls and floor also were saturated with dirt.

On K3 the patient refrigerator and freezer located in the kitchenette had particles of food laying on the bottom shelves of each. The Chief Operating Officer (COO) stated that the clinical staff are to maintain and clean the refrigerator in the kitchenette at the time of the observation. In the K3 dining room, a locked cabinet was under the sink. In the cabinet there was a dark brown residue and the drainpipe had a leak and a wet spot noted bellow the pipe. Observation in patient room K3-23 the lower walls were saturated with dirt by the kick boards.

On K8 the lower cabinet left of the sink in the dining room was locked. When opened by staff, mouse droppings were observed throughout, with packets of creamer that appeared to be chewed open by mice. No mouse traps were observed in the area.

In the facility's main kitchen, mouse droppings were in the dry storage closet between the prep area and large sink area.

All findings were verified by the Staff A, Staff B, and Staff C at the time of the observations.

2. Review of the "Commissary Report" for January 2020 revealed mouse droppings were found on 01/03/20 and 01/10/20. The plan states "will continue regular checks in commissary room".

3. Review of the facility's infection control rounds documentation revealed in February 2020, evidence of mice were observed in the kitchen. On the April 2020 rounds, mouse droppings were observed on K6 under the microwave. . On the May 2020 rounds, not applicable was documented for all the patient units. On the June, July, and August 2020 rounds state there were no infection control issues. There was nothing documented about addressing the mouse droppings in the facility.

On 09/02/20 at 1:00 PM the Infection Control Nurse, Director of Performance Improvement, and the COO were not able to show additional information that other actions were taken beyond notifying the supervisors and maintenance staff of the mouse issue.

4. Review of the "Housekeeping Daily Schedule" revealed that the dining area is to be a "full clean" and sanitize. Also, patient rooms daily cleaning schedule states "full clean" and sanitize.

5. Interview with the Staff E completed on 09/02/20 at 10:30 AM revealed there is no environmental staff available in the evenings and nights. He/she also verified that "full clean" on the "Housekeeping Daily Schedule" means floors, walls, counters, etc.

6. Interview with the Staff C completed on 09/02/20 revealed that clinical staff are to maintain cleanliness during hours environmental cleaning staff are not available.

7. Observation of the dining area for unit K9 on 09/08/20 revealed under the cabinet to the right of the sink there were a few mouse droppings present in the cabinet. When opening the cabinet, it was hard to open due to a sticky brownish residue on the face of the cabinet and on the inside of the door. The top of the refrigerator had a thick film of dust with a couple of brownish spots. These findings were verified by the Director of Performance Improvement and the Infections Control nurse at the time of the observations.

8. No requested policies related to clinical staff cleaning, as requested on 09/02/20, was provided before exiting the facility on 09/08/20.