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Based on observation, interview, and policy review, the Infection Control Officer failed to ensure that staff followed the general policy for cleaning stretchers (beds) in three (#3, #4 and #2) of three Emergency Department (ED) rooms. This failure increased the risk of hospital-acquired infection (HAI) for all patients treated in the ED. The facility treated an average of 30 ED patients per day. The facility census was 16.

Findings included:

1. Record review of the facility's policy titled, "General Cleaning for ED stretchers and beds" dated 05/2015, showed directives for staff:
- Use wipes with cleaning product to wipe surfaces.
- Gross decontamination will be done first as needed, followed by the antibacterial germicidal wipe use.
- Equipment will be checked for cleanliness prior to each patient use.
- Charge Registered Nurse (RN) will assess stretchers for cleanliness at the beginning of each shift.
- Equipment will be cleaned after patient or staff use.

2. Observation with concurrent interview in the ED room #3, on 05/27/15 at 9:00 AM showed tape residue (sticky substance, rendering bed rail uncleanable, which allowed for germs to stick and multiply) on the right side rail of the stretcher and dried pink residue on the left side rail of the stretcher. Staff M, RN, and Staff I, Director Laboratory/Infection Control Officer, confirmed the tape residue and the dried pink residue were on the side rails.

3. Observation with concurrent interview in the ED room #4, on 05/27/15 at 9:15 AM showed tape residue on the right side rail of the stretcher. Staff M and Staff I confirmed the tape residue was on the side rail.

4. Observation with concurrent interview in the ED room #2, on 05/27/15 at 9:35 AM showed dark red residue, approximately one inch long by a quarter of an inch wide, on the right side rail and dried yellow debris, approximately the size of a quarter, on the left side rail of the stretcher. Staff M and Staff I confirmed that the residue was on each of the side rails. Staff I stated that she had failed to identify the soiled bed rails during her weekly environmental rounds. Staff I stated that the ED staff failed to follow the recent training on the cleaning policy for the stretchers.

During an interview on 05/27/15 at 9:40 AM, Staff N, Vice President of Quality Assurance Performance Improvement, confirmed the finding of unclean bed rails.

During an interview on 05/27/15 at 9:50 AM, Staff H, Chief Nursing Officer, stated that his expectation was that the ED stretchers would be cleaned and wiped down with disinfectant after each patient use and that staff would follow the cleaning policy.


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