HospitalInspections.org

19043



Based on observation, in one (1) of one (1) patient care and staff interview, it was determined the facility did not ensure; (a) infection control practice was utilized in the care of patients (b) a sanitary environment is maintained in all areas of the hospital to prevent sources and transmission of infections/communicable diseases. (Patient #1).

Findings include:

1. On 11/6/15 at approximately 2:15 PM, Staff A (Respiratory Therapist) was observed during administration of aerosol treatment to Patient #1. The patient was on contact precaution for Klebsiella pneumonia in blood and multi-drug resistant organisms (MDROs) in wound.

Staff A donned a gown and gloves and wheeled the respiratory cart into the patient's room, thereby contaminating the cart. After the administration of treatment to Patient #1, Staff A contaminated the computer on the cart by charting patient's data while wearing his used gown and gloves.

The inspection of the respiratory cart revealed a cup of coffee belonging to Staff A was stored in a drawer together with respiratory supplies and medications.

During interview with Staff B on 11/6/15 at 2:30 PM, she acknowledged the breaches in infection control practice.



2. During the tour of the Emergency department on 11/06/15 at approximately 10:00 AM, the following were observed:

(a) The perimeter of the floor throughout the Emergency room was heavily soiled and grimy.

(b) The floor of the cubicles with bed #s24, 25, and 29 was heavily soiled and was observed to be black in color.

(c) The cove base was observed to be peeling off from the wall in various areas throughout the Emergency Department, including room #17 and by the ambulance entrance.

(d) Holes in the walls were also observed in various locations throughout the Emergency Department including the area by the clean supply cart.

(e) The ambulance entrance was observed to be unkempt with piles of garbage and dirt throughout the ramp. The surveyor observed a backboard placed on the dirty muddy ramp. There were three other backboards hung on the wall close to the floor and the straps were touching the floor.

(f) The Wooden shelves beneath the counter top by bed #24 and bed #25 were chipped and in disrepair. Therefore, the surfaces of these shelves were not cleanable.

(g) The equipment in the Emergency department was observed to be dusty. The carts of two Electrocardiogram (EKG) machines (biomed#s15329 and 15339) were covered in dust. Dust was observed in the drawers used for storing EKG leads. The wheels of the carts were observed to be black in color with pieces of adhesive tape stuck on them.

(h) The surveyors observed Staff C, Patient Care Associate (PCA), and Staff D; housekeeper cleaned and prepared the bay by Bed #15 to receive a patient. Staff D placed a container of bleach wipes on the garbage bins and Staff C pulled clean wipes and squeezed the bleach solution back into the bleach container with soiled gloves he used to clean the mattress and hand rails of the stretcher. Staff D, during the process of cleaning the floor touched the clean handrails of the stretcher bed with soiled gloves he used to touch the red bag waste bin. Staff D did not wipe the handrails again until he was advised by the nurse manager of the Emergency Department.


3. During the tour of the Operating Rooms and the Endoscopy room on 11/06/15 at approximately 11:30 AM, the following were observed:

(i) The pole of the patient monitor was rusty, rendering the surface difficult to clean and disinfect.

(j) The decontamination room for endoscopy did not have a handwashing sink.

(k) The metal cabinets for storage of clean supplies in OR #1 was observed to be rusty. The pole of the relocatable power tab was also observed to be rusty in OR #1.


(l) The ceiling tiles in the central core of the Operating suite, the central sterile room, and in the isolation rooms of the Emergency Department and on the 8th floor, were of the type that cannot be washed /cleaned.

Interview was conducted on 11/6/15 at 11:35 AM with Staff E, Clinical Nurse Manager for Peri-Operative Services regarding the lack of handwashing sink in the decontamination room.
Staff E stated that staff members use the decontamination sink or the Endoscopy room sink for handwashing.

Staff E acknowledged the lack of cleanable ceiling tiles in mandated areas of the hospital and stated that tiles are replaced when they are visibly soiled.



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