HospitalInspections.org

Based on a review of facility policies, documentation, photographs, and interview with staff (EMP) it was determined the facility failed to ensure that the patient's right to care in a safe setting was maintained.

Findings include:

A review of facility policy "Patient and Family Rights and Responsibilities" effective date November 7, 2014, revealed, "You can expect CHOP to: ... Provide care in a safe and secure setting, ... ."

1. A review on March 14, 2018, with EMP1, EMP3 and EMP4 of a photo taken by the complainant revealed five bed pillows on top of a dirty linen cart inside patient's room 8S12.

An interview conducted on March 14, 2018, at 10:00 AM with EMP1, EMP3 and EMP4 confirmed that the photo taken by the complainant revealed five clean bed pillows on top of a dirty linen cart inside patient's room 8S12. In addition, EMP1 confirmed that there was a lack of clean storage area in the patient's room for staff to temporarily place clean linen. Further interview with EMP4 confirmed that the clean bed pillows on top of a dirty linen cart were intended for the patient's parents' use and not for patient use.

2. A review on March 14, 2018, with EMP1, EMP3 and EMP4 of on-line mandatory, annual infection prevention and control education required and completed for all staff revealed, "Environment of Care Separation of Clean and Dirty All CHOP employees need to adhere to a clear separation of clean and dirty. ... . DO.. Prevent contamination and transmission of germs by always keeping clean areas and items separate from dirty ones. ... . DO NOT.. Place clean items on dirty items. For example, clean items should not be placed on trash can lids or soiled linen containers. ... ."

A review of Environmental and Linen Services Department policy "Overall Service Provision of Reusable Textiles (Linen)" revealed, "Ensure that clean linen will always kept separate from soiled linen. ... ."

An interview conducted on March 14, 2018, at 10:15 AM with EMP1, EMP3 and EMP4 confirmed that staff had not followed their policies and training guidelines to assure separation of clean and dirty linens.

3. A review on March 14, 2018, with EMP1, EMP3 and EMP4 of a photo taken by the complainant revealed a partial name sticker for a different patient, on the foot rail of the patient's crib.

A review on March 14, 2018, of the task aide checklist for "Springfield Crib Cleaning" revised 6/9/2017 revealed, "Remove all visible debris such as tape and stickers from crib."

An interview conducted on March 14, 2018, at 2:00 PM with EMP1, EMP3 and EMP4 confirmed that the the photo showed a partial, illegible name sticker of another patient on the foot rail of the patient's crib. Further interview confirmed that the staff had not completely followed the task aide checklist requirements for crib cleaning.