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Based on observation, Environmental Services Policy Manual review and interview, it was determined the facility failed to assure patient's rooms and patient equipment were clean. Failure to maintain a clean environment had the potential to expose patients and staff to a greater risk for infections. This failed practice had the potential to affect all patients admitted to the hospital. The findings are:

Tour of the 2nd Floor Medical Surgical Department was conducted on 04/03/12 at 0930-1030 with the Director of Nursing (DON). The following was observed and confirmed by the Director of Nursing at the time of observation:

1. Patient Room 206 unoccupied and identified by the DON as clean and ready for patient occupancy revealed the four bedrails contained stains of a dark brown unknown substance. An Intravenous (IV) pump contained an accumulation of unidentified stains and the IV pole and base contained a buildup of dust. Dead bugs were observed in the toilet and the mattress contained frayed edges and cracks in the surfaces.

2. Patient Room 207 unoccupied and identified by the DON as clean and ready for patient occupancy revealed the four bedrails contained stains of a dark brown unknown substance. An Intravenous (IV) pump contained an accumulation of unidentified stains and an IV pole and base contained a buildup of dust. The mattress contained frayed edges and cracks in the surfaces. Dead bugs were observed in the toilet and the mattress had frayed edges and cracks in the surfaces.

3. Patient Room 208 unoccupied and identified by the DON as clean and ready for patient occupancy revealed the four bedrails contained stains of a dark brown unknown substance. An Intravenous (IV) pump contained an accumulation of unidentified stains and the IV pole and base contained a buildup of dust. The over bed table contained an accumulation of dust and unidentified stains.

4. Patient Room 209 unoccupied and identified by the DON as clean and ready for patient occupancy revealed the four bedrails contained stains of a dark brown unknown substance. An Intravenous (IV) pump contained an accumulation of unidentified stains and the IV pole and base contained a buildup of dust. Dead bugs were observed in the toilet.

5. Patient Room 210 unoccupied and identified by the DON as clean and ready for patient occupancy revealed the four bedrails contained stains of a dark brown unknown substance and the Intravenous (IV) pump and pole contained unidentified stains and a dust buildup. A Geri-chair in the room contained stains of a dark brown unknown substance.

6. Patient Room 213 occupied revealed the four bedrails contained stains of a dark brown unknown substance, the floor underneath the toilet and the shower wall contained a buildup of dirt and grime. An Intravenous (IV) pump contained an accumulation of unidentified stains and the IV pole and base contained a buildup of dust.

7. Patient Room 219 occupied revealed the four bedrails contained stains of a dark brown unknown substance. An Intravenous (IV) pump contained an accumulation of unidentified stains and the IV pole and base contained a buildup of dust. The mattress contained frayed edges and cracks in the surfaces.

8. Patient Room 220 occupied revealed the four bedrails contained stains of a dark brown unknown substance. An Intravenous (IV) pump contained an accumulation of unidentified stains and the IV pole and base contained a buildup of dust. Corner base board was missing.

9. Patient Room 221 occupied revealed the four bedrails contained stains of a dark brown unknown substance. An Intravenous (IV) pump contained an accumulation of unidentified stains and the IV pole and base contained a buildup of dust.

10. Patient Room 222 occupied revealed the four bedrails contained stains of a dark brown unknown substance. An Intravenous (IV) pump contained an accumulation of unidentified stains and the IV pole and base contained a buildup of dust.

Based on observation, Environmental Services Policy and Procedure Manual review and interview, it was determined the facility failed to ensure written policies and procedures were in place to maintain a clean and sanitary environment. Without environmental care policies and procedures, it could not be determined staff followed current environmental cleaning guidelines. The failed practice had the potential to exposed all patients admitted to the hospital to an unsanitary environment. Findings follow:

A. Review of the Environmental Services Policy Manual on 04/04/12 at 1215 revealed the absence of "Title III Cleaning Procedures" policies. The Director of Nursing stated the policies were all missing and the second Environmental Services Policy Manual was missing the same "Title III Cleaning Procedures" policies.

B. Interview with the Director of Nursing on 04/04/12 at 1220 confirmed there were no environmental cleaning policies and procedures.