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1d. In the mid afternoon on 10/19/11, in the first floor ladies public bathroom, the surveyor observed a nursing staff educator cleaning and disinfecting CPR equipment using the sink plus a plastic tub, sitting on the counter, for disinfecting. There was a jug of bleach present, and the surveyor asked the staff member what strength bleach water she used to disinfect the equipment. She replied she wasn't sure. She said she filled the plastic tub up to about 3/4 full and added an ounce of bleach. No policy for disinfecting CPR equipment was presented.


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Based on observations, staff interviews and review of product label information the facility staff failed to ensure
1 a. ice machine in the emergency department had an air gap,
1 b. kitchen staff used the appropriate amount of chemical concentration in the water to clean and disinfect pots, pans and dishes and that pots and pans were not stored stacked and wet and that clean towel and aprons were not stored with dirty mops, brooms and dust pans
1 c. appropriate amount of disinfectant chemicals per recommended water amounts were used to clean surgical instruments.
2. appropriate and recommended bleach to water ratio was used when cleaning instruments used in teaching CPR

The Findings Include:

1a. During the initial tour on 10/18/11 of the facility's Emergency Department (ED), Dietary Services and Surgical Departments with the Senior Leader of Surgical/Outpatient Services the ice machine in the "fast track" area of the was observed. The drain pipe from the ice machine was observed touching the side of the drain hole. The end of the drain pipe was below the floor level.

The Senior Leader of Facility Services and Environmental Services was called to the area. He observed the ice machine and was asked if it had an air gap. He stated, "No but it will shortly."

1b. During the initial tour of the kitchen with the Senior Leader of Surgical/Outpatient Services and the Dietary Manager the 3 part sink was observed. The Dietary Manager was asked how the staff knew how much water was to be placed in the sink with the automatically measured chemical for cleaning. She stated, "There should be a mark in the sink so they would know how much water to put in the sink and there is no mark."

Also during the tour of the kitchen a small room was observed the Dietary Manager stated the room was the "chemical room". The room held dirty wet mops, mop buckets, brooms, dust pans, cleaning chemicals and a bin of uncovered clean towels and aprons. The Dietary Manager stated, "They are bar towels used to wipe off the bars around the food." "They probably should not be in here with the wet mops."

1c. On 10/18/11 during the initial tour with the Senior Leader of Surgical/Outpatient Services the decontamination room was observed. The staff member responsible for cleaning instruments was present. The staff member explained the appropriate amount of the cleaning chemical (Prolystica Ultra Concentrate Enzymatic Cleaner) is dispensed when a button on the dispenser is pressed. She was asked how much water was used and she stated, "About one gallon." The staff member was asked to show how much a gallon of water was in the large 3 part sink. The staff member pointed and stated, "About at the bottom of this wash cloth." A wash cloth was hanging on the dividing wall between two parts of the sink. She was asked to close the sink and measure out 1 gallon of water. She looked around and could not locate an instrument to measure the water with. She located an empty 1 gallon jug, filled it was water and poured it into the closed sink. The water barely covered the bottom of the sink. She stated, "That is not enough water."

The enzymatic presoak and cleaner label states in manual/ultrasonic applications to dilute 1/8 to 1/2 fl. oz. per gallon of warm water.