Bringing transparency to federal inspections
Tag No.: A0713
Based on observation and staff interview the facility failed to ensure that their bagged trash was stored properly in two (2) out of seventeen (17) soiled utility rooms observed. This failure has the potential for all patients and staff in the facility to be contaminated with soiled garbage, cardboard and linens. The facility's census was 303.
Findings include:
1. An observation on 12/13/21 at approximately 11:55 a.m. revealed the Pediatrics Intensive Care Unit's (PICU) soiled utility room located on the fifth (5th) floor had no trash cart. There were six (6) bags of trash on the floor that were leaking a sticky substance onto the floor. There were also bagged suction containers that were not in the bio-hazard bin.
2. An observation on 12/13/21 at approximately 12:10 p.m. revealed the general Pediatric Unit's soiled utility room located on the fifth (5th) floor had no trash cart. There were two (2) bags of trash on the floor as well as two (2) bags of soiled linen. There was also a large stack of cardboard boxes on the floor.
3. These findings were discussed during an interview with the Housekeeping Supervisor on 12/13/21 at approximately 12:20 p.m. These findings were discussed again upon exit on 12/14/21 with the Housekeeping Supervisor and Safety Officer and they concurred with the findings.
Tag No.: A0750
A. Based on observation, document review and interview it was revealed the facility failed to maintain a clean environment to prevent the transmission of disease in two (2) out of seventeen (17) soiled utility rooms. This failure has the potential to negatively impact all patients receiving care at the facility.
Findings include:
An observation of a soiled utility room on the fifth (5th) floor Pediatric Intensive Care Unit on 12/13/21 at approximately 11:55 a.m. revealed six (6) bags of trash on the floor. A sticky substance was noted on the floor.
An observation of a soiled utility room on the fifth (5th) floor general Pediatric Unit on 12/13/21 at approximately 12:10 p.m. revealed two (2) bags of trash, two (2) soiled laundry bags and a stack of cardboard boxes on the floor.
A policy titled "Normal Trash Removal," last revised 01/20, was reviewed. The policy states in part: "...III. Procedure...C. The liner of trash is taken to the trash chute or placed in a gray trash cart ..."
A policy titled "Cardboard Box Removal," last revised 01/20, was reviewed. The policy states in part: "...III. Procedure...b. Load boxes into gray trash carts, whether broken down or not ..."
A policy titled "Cleaning Procedures Ancillary Areas," last revised 01/20, was reviewed. The policy states in part: "...III.Procedure...D.Utility Rooms-Daily Cleaning...3.Counter Tops, Shelves, Sinks, Hoppers...j.Wet mop floors with disinfectant ..."
An interview was conducted with the Housekeeping Supervisor on 12/13/21 at approximately 12:20 p.m. The supervisor stated, "The bags should be in bins, not on the floor."
B. Based on observation, document review and interview it was revealed the facility failed to ensure visitors were screened upon entry into the facility to prevent the transmission of COVID-19 in three (3) out of three (3) surveyors who presented to the facility.
Findings include:
On 12/13/21 at approximately 11:15 a.m. three (3) surveyors presented to the information desk. The Guest Services representative did not ask the posted COVID-19 screening questions. The surveyors were then taken to the administration area.
On 12/14/21 at approximately 8:00 a.m. surveyor #1 met the Regulatory Coordinator in the main lobby. Surveyor #1 walked past the information desk and to the administration area. No COVID-19 screening questions were asked.
On 12/14/21 at approximately 9:00 a.m. surveyor #2 walked past the information desk and to the administration area. The surveyor was not stopped and no COVID-19 screening questions were asked.
On 12/14/21 at approximately 9:30 a.m. surveyor #3 walked past the information desk and on to the administration area. The surveyor was not stopped and no COVID-19 screening questions were asked.
CDC (Centers for Disease Control) Guidance from CDC.gov "Infection Control Guidance" states in part: "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic," last updated 09/10/21, "1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic. Establish a Process to Identify and Manage Individuals with Suspected or Confirmed SARS-CoV-2 Infection... Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following so that they can be properly managed: 1) a positive viral test for SARS-CoV-2, 2) symptoms of COVID-19, or 3) who meets criteria for quarantine or exclusion from work. Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which individuals can self-report any of the above before entering the facility ..."
An interview was conducted with a Guest Services representative on 12/14/21 at 2:00 p.m. The Guest Services representative stated, "I screen everyone except employees. We try to make sure we catch anyone walking by to verify if they are an employee or a visitor who needs to be screened. All visitors get screened including vendors and surveyors."
An interview was conducted with the Director of Patient Experience on 12/14/21 at 11:33 a.m. Regarding visitor screening, the Director of Patient Experience stated, "The visitors are supposed to come in through the funnel and stop at the information desk for the screening. They are given an armband indicating they have been screened. They are supposed to stop anyone walking by who doesn't stop at the information desk and inquire if they are a visitor and complete the screening. You (surveyors) should have been screened."