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Based on observation, policy review, and interviews, it was determined the facility failed to ensure staff properly managed dirty linens in 1 (Patient #5) of 7 patient rooms. This failure had the potential to create an unsanitary environment.

Findings included:

A review of the facility's policy titled, "Standard & [and] Transmission Based Precautions," published 10/12/2021, revealed "Standard Precautions are the minimum infection prevention practices that apply to all patient care, regardless of suspected or confirmed infection status of the patient, in any setting where health care is delivered. These practices are designed to both protect healthcare worker and prevent healthcare worker from spreading infections among patients. Standard Precautions include: 1. Perform Hand hygiene as appropriate 2. Use personal protective equipment (e.g., gloves, procedure masks, eyewear) whenever there is an expectation of possible exposure to infectious material 3. Follow Respiratory hygiene/cough etiquette principles (cover cough/sneeze) 4. Follow Sharps safety engineering and work practice controls 5. Follow Safe injection practices (i.e., aseptic technique for parenteral medications). i.e., wearing surgical mask when performing lumbar punctures 6. Use sterile instruments and devices as indicated. 7. Clean and disinfected environment as appropriate following manufacturer's instruction guidelines 8. Handle textiles and laundry in safe manner 9. Ensure appropriate patient placement."

During a tour of the third-floor medical surgical unit on 10/18/2022 between 10:45 AM and 11:30 AM, the surveyor noted a strong smell of feces odor and dirty soiled linen was observed lying on the floor in Patient #5's room.

An interview on 10/18/2022 at 11:00 AM with a family member seated at Patient #5's bedside revealed the soiled linen had been lying on the floor since the family member arrived more than two hours prior.

In an interview on 10/28/2022 at 11:05 AM, Patient #5 stated staff cleaned and changed the bed but never came back to dispose of the soiled linens. The surveyor observed Patient #5's bed linens had been changed but the soiled bed linen was left lying on the floor near the linen hamper. The linen hamper was missing a linen bag and soiled linen was lying across the bottom of the linen cart on the floor and a strong odor of feces was noted in the room.
In an interview on 10/18/2022 at 11:10 AM, Registered Nurse (RN) #4 stated the care partner (nurse aide) had last changed Patient #5 during morning rounds. RN #4 gave no explanation regarding why soiled linen was left on the floor of Patient #5's room. RN #5 referred the surveyor to the care partner who last changed Patient #5's soiled bed/linens.

In an interview on 10/18/2022 at 12:20 PM with the care partner who provided care for Patient #5 on 10/18/2022, she stated the linen cart did not have a linen bag when she changed Patient #5, so she put the soiled linen on the floor. The care partner stated, "It's my fault, I just forgot to go back."

During a telephone interview on 10/20/2022 at 10:00 AM, the Infection Control Nurse gave no explanation why the care partner left feces-soiled linen on the floor of Patient #5's room.