HospitalInspections.org

Based on observations, interviews, and document reviews, the hospital failed to have a system to ensure the maintenance of a sanitary environment to prevent potential infections in 6 of 17 areas (Medical/Surgical Unit, Special Care Unit, Emergency Department, Birthing Center, Rehabilitation Services and Radiology).

Findings include:

1. On April 23, 2018 at 9:55 AM, during a tour of the Emergency Department with the Director of Ambulatory Services and Emergency Department Nurse Manager, the following was observed:

- Significant accumulation of visible dust on an emergency code cart behind the nurses' station, indicating a lack of sufficient cleaning and sanitization.

- Visible dust on a bladder scanner, indicating a lack of sufficient cleaning and sanitization.

The surveyor confirmed the findings, with the Director of Ambulatory Services and Emergency Department Nurse Manager, at the time of the observation.

2. On April 23, 2017, from 10:00 AM to 2:45 PM, during tours of the hospital with the Clerical Assistant of Plant Operations, the following was observed:

a. A significant accumulation of dust, indicating a lack of sufficient cleaning and sanitizing:

- In Medical/Surgical Patient Room 208, on the upper surface of the cabinet doors, the upper edge of the television, and the upper edge of the dry-erase board.

- In Medical/Surgical Patient Room 209, on the upper surface of the cabinet doors and the upper edge of the television.

- In Medical/Surgical Patient Room 210, on the upper surface of the clock.

- In Medical/Surgical Patient Room 212, on the upper surface of the cabinet doors.

- In Medical/Surgical Patient Room 221, on the light above the bathroom sink.

- In Medical/Surgical Patient Room 222, on the upper surface of the cabinet doors.

- In Special Care Unit Patient Room 3, on the upper edge of the dry-erase board.

- In Special Care Unit Patient Room 4, on the top of the wall hung picture, the upper edge of the television, and the upper edge of the dry-erase board.

- In Special Care Unit Patient Room 6, on the top of the wall hung picture, the upper surface of the mantel that runs along the upper wall over the head of the bed, the upper surface of the door frame, and the bottom of the bed frame.

- In Birthing Center Room 111, on the upper surface of the over the sink light in the bathroom.

- In the Nursery of the Birthing Center, on the top of two infant warmers, and on the upper edge of a drawer of a basinet.

- In the Emergency Department Room 6, on the base of a stretcher.

b. In the Rehabilitation Gym, a cracked surface on a crutch arm pad was observed. This cracked surface created a surface that could not be easily cleaned and sanitized.

c. In Medical/Surgical Rooms 207, 208, 209, 211, 212, 213, 224, 226, 227, and in Infusion Room 215, unfinished tops on bathroom doors were observed. These unfinished tops created surfaces that could not be easily cleaned and sanitized.

- In Special Care Unit Rooms 1, 2, and 3, cork boards were observed. These corkboards created surfaces that could not be easily cleaned and sanitized.

All the above findings were confirmed, with the Clerical Assistant of Plant Operations, at the time of the observations.

3. On April 24, 2018, from 9:00 AM to 11:30 AM, during tours of the hospital with the Director of Plant Operations, the following was observed:

a. In Radiology Room 5, X-Ray Room 3, and in the Nuclear Medicine Room, rust on the base of linen hamper carts. The rust created a surface that could not be easily cleaned and sanitized.

b. In Radiology Room 6, rust on the base of the intravenous pole on the stretcher. The rust created a surface that could not be easily cleaned and sanitized.

c. In Emergency Department Room 10, a significant accumulation of dust on the dry erase board, indicating a lack of sufficient cleaning and sanitizing.

d. In Emergency Department Rooms 7 and 10, a significant accumulation of dust on the upper edge of the cupboard doors.

4. On April 24, 2018 from approximately 11:00 AM to 11:15 AM, staff were observed and interviewed when disinfecting areas of the Medical/Surgical and Special Care units. The following was noted:

a. Physical Therapist (PT) #1 was observed disinfecting a walker (a device used to assist a person to walk), using a single wipe from a container of labeled, "Clorox Bleach Germicidal Wipes". The surveyor observed that the surface of the walker was visibly drying within 20 seconds of being wiped. The RN did not re-wipe the walker to ensure it remained wet for at least three minutes. The manufacturer's label on the container of Clorox Bleach Germicidal Wipes was observed. The manufacturer's label indicated the "wet time" (i.e., the time a piece of equipment needs to remain wet for proper disinfection) must be three minutes to provide appropriate sanitizing of the item. When asked about wet time for the wipes, PT#1 replied, "It means that is how long it takes for it to dry before you can use it."

b. Housekeeper (HK) #1 was observed cleaning Patient Room 210. During an interview HK#1, she reported that the disinfecting agent that was she was using was called "Hyperfect". She indicated Hyperfect takes "three to ten minutes to dry." The manufacturer's instructions provided with Hyperfect indicated the "wet time" (i.e., the time a piece of equipment needs to remain wet for proper disinfection) must be ten minutes to provide appropriate sanitizing of the item. When asked about the meaning of "wet time", HK#1 replied, "It means you wipe it and leave it and it takes ten minutes for it to dry. You can't do anything to it for ten minutes." When asked, "So if it dries before the ten minutes is up, is that OK?" HK#1 replied, "Yes. I've never really timed it ... we don't time it ..."

c. Housekeeper (HK) #2 was observed cleaning a Special Care Unit Room using "Hyperfect" disinfectant liquid. When asked about the use of the Hyperfect disinfecting agent, HK#2 reported, "Wipe it down ... the dry time is ten to fifteen minutes", and, you wipe it once and it's 10 minutes before you can use it." When asked, "So if it dries before the ten minutes is up, is that OK?" HK#2 replied, "Yes, we get it wet enough to kill the germs but not so it takes too long to dry so the nurses can have the room if they want it." HK#2 was also asked regarding the use of Clorox Bleach Germicidal Wipes. HK#2 reported, "It takes three minutes to dry. We wait for three minutes for it to dry and then the nurses can use the room. It does dry quite quickly, though. Even though they say three minutes, it dries faster than that." When asked, "So if it dries before the three minutes is up, is that OK.", HK#2 replied "Yes."









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