HospitalInspections.org

Based on observation, interviews and facility document review, the facility failed to maintain/repair malfunctioning ED equipment to ensure a level of safety and quality.

The findings include:

On April 28, 2025 at 12:30 PM, a tour of the facility's Emergency Department (ED) was conducted with Staff Members #4, #17 and #18. During the tour, the surveyor observed a malfunctioning overhead light in ED patient room G04. Patient #3 included in the survey sample reported that during their ED visit on April 11, 2025 the overhead light was not functioning and the provider elected to use the flashlight on their phone during a pelvic exam.

Staff Member #17 indicated during the tour that if an overhead light in one of the patient rooms was not functioning, staff had to place a work order and maintenance would repair the issue. Staff Member #17 stated that their maintenance department did not do routine maintenance checks on the equipment in the ED patient rooms and they rely on staff to place a work order if something is non-operational or malfunctioning. Staff Member #17 explained that the ED has portable lights that can be brought into a patient room if an overhead light is not functioning or sufficient and speculums used for pelvic exams also contained a build-in light source.

On April 28, 2025 at 2:00 PM, three (3) ED complaints/grievances received by the facility between February 1, 2025 and present and related to the cleanliness of the ED were reviewed. One (1) of the logged complaints was from Patient #3, included identical allegation as investigated during this survey and was received by the facility on April 18, 2025.

On April 28, 2025 at 4:45 PM, Staff Member #2 stated that facility staff were not aware of the malfunctioning overhead light in ED room G04 until today and that upon discovery a work order was placed for a repair. Staff Member #17 explained "a non-employee" provider did not notify an ED staff member of the issue nor placed a work order for repairs. Staff Member #3 stated that the patient complaint about the malfunctioning overhead light was probably not addressed sooner because the Grievance Department only received the complaint on April 18, 2025 and the Grievance Department has 30 days to resolve that complaint from the date of receipt.

On April 28, 2025 the surveyor requested to interview Staff Member #24, who performed a pelvic exam on a Patient #3 in ED room G04 on April 11, 2025. At the time of the exit conference on April 29, 2025, neither the survey team nor the facility received a call-back from the contracted staff.

On April 29, 2025 at 11:10 AM, a review of Staff Member #24's personnel file was conducted with Staff Member #25. The personnel record revealed that Staff Member #24 was granted privileges to provide services within the facility. The personnel record also revealed that Staff Member #24 signed an "Information Release/Acknowledgment" letter documenting that they agreed to abide by the facility's policies and procedures. Staff Member #25 stated that prior to being granted privileges, providers are sent copies of the facility's By-Laws and Policies and Procedure to review.

Based on observation, interviews and facility document review, the facility failed to ensure adequate cleaning and disinfection of the Emergency Department patient rooms.

The findings include:

On April 28, 2025 at 12:30 PM, a tour of the facility's Emergency Department (ED) was conducted with Staff Members #4, #17 and #18. During the tour, Staff Member #17 indicated that the ED had their own, dedicated Environmental Services (EVS) staff and uses a system called teletracking. When a patient is discharged from a patient room, a notification is sent to the EVS staff to alert them that the room needs to be cleaned. Once the EVS staff completes the cleaning, EVS staff changes the room status to "clean" and the system notifies clinical staff that the room is ready for a new patient. Staff Member #17 explained that when cleaning patient rooms staff are expected to wipe down all surfaces with disinfectant, clean floors, remove trash and dirty linen and replace with clean linens.

On April 28, 2025 at 3:10 PM, a review of Patient #3's medical record was reviewed with Staff Member #17. Patient #3's medical record documented that Patient #3 was placed in room G04 on April 11, 2025 at 7:49:13 PM.

On April 29, 2025, the surveyor reviewed the facility's EVS teletracking log and found that on April 11, 2025 at 7:39:05 PM, room G04 was "dirty". An EVS staff member documented that room G04 was "in progress" for cleaning at 7:41:00 PM. The same EVS staff member documented at 7:42:26 PM that room G04 was "clean". The documentation revealed that the EVS staff member "cleaned" room G04 in one (1) minute and 26 seconds. The log didn't contain documentation that additional staff assisted in cleaning of the room G04 during that time. The log also documented that room G04 was "occupied" at 7:49:25 PM.

On April 29, 2025 at 12:10 PM, during an interview Staff Member #23 stated that the approximate average time to clean/disinfect a patient room by one staff is about 14 minutes. Staff Member #17 commented that the logged timeframe of one (1) minute, 26 seconds by the EVS worker for cleaning of room G04 on April 11, 2025 at 7:42 PM was not an appropriate amount of time for the one (1) EVS staff member to properly clean the room. However, Staff Member #23 explained that it was possible that there was another staff member cleaning the room at the same time, but the documentation in the teletracking log did not capture that. Staff Member #23 indicated that if EVS staff got a notification that a room needed to be cleaned "STAT", more than one person would help with the cleaning if there were enough staff available. Staff Member #23 further indicated that EVS staff did not handle any biohazard waste products, such as a urine, blood, bodily fluids. The clinical staff were responsible to dispose of the biohazard waste products. SM23 did not provide a policy/procedure regarding the facility's process for EVS staff members logging into the EVS teletracker, nor for providing support to clinical staff with removal biohazard waste.

On April 29, 2025, a review of the facility's policy "9.10 - Emergency Room Cleaning and Disinfection", issued 10/1/2024, indicated in part: "...Procedure...Remove trash from patient suites, High dust and disinfect vertical surfaces, including doors, walls, doorknobs, light switches, and IV poles, Disinfect horizontal surfaces such as bedside tables, ledges, sink surfaces, and dispensers, clean or remove Privacy Curtains based on patient condition (isolation status). If using disposable curtains, dispose of them according to facility guidelines where applicable, refill hand soap and towels if needed, dry mop floor and place a caution/wet floor sign, inspect work to ensure all areas are cleaned to standard, damp mop floor surfaces with disinfectant using either traditional or microfiber methods...".

On April 29, 2025, a review of the facility's policy "7.10 - Clinical Exam Room Cleaning Procedure", issued 10/1/2024, indicated in part: "...Procedure...Place caution/wet floor sign at room entrance prior to beginning assignment, remove exam room trash from the cans, damp wipe the can and replace the liner...Place clean liners into the waste cans...Bring caddy containing chemicals and plastic pail into the room, along with high dusting tool, high dust, beginning at the entranceway and working around the room in a circle. High dust horizontal surfaces above shoulder height starting opposite the restroom...Using germicidal/disinfectant cleaner and a microfiber clean cloth, disinfect/sanitize all patient contact surfaces, including exam table, phone, chairs, low ledges and counter, light switches and doorknobs...spot wipe/disinfect stains and spots from walls and other vertical surfaces...Generally heavy body fluids including but not limited to blood, feces, etc. are handled by the clinical staff with support from EVS....Remove caddy and high dusting from the room and place on the cart, Dust mop the room beginning with corners and edges, moving from the far side of the room toward the door...Dust under the bed, furniture and behind the door. Leave the dust mop at the door. Bring the dustpan and counter brush/squeegee to the doorway...damp mop hard surface floors beginning with corners and edges, moving from the far side of the room toward the door...".

On April 29, 2025 at 12:35 PM and during the exit conference, Staff Member #3 presented video surveillance footage that captures room G04 being cleaned on April 11, 2025 at 7:40 PM by two (2) EVS staff members. The video camera was installed near the ceiling in an ED hallway, room G04 was visible on the opposite end of the hallway as the camera and the video footage was not angled to capture a view of events occurring inside the room. The footage revealed two (2) EVS workers approach the doorway of room G04 with the cleaning caddy, one (1) staff member was seen entering the room, while the other EVS staff member stood in the hallway for approximately 15-20 seconds, looking down at something in their hand. Afterwards, that EVS staff was seen entering room G04 with the first EVS staff. Neither EVS staff pulled the cleaning caddy into the room. The EVS staff were in the room for approximately two (2) minutes and 45 seconds. Both exited room G04 at approximately 7:42 PM and pushed the cleaning caddy around the corner. Neither staff appeared to carry out a trash bag or a dust mop.