HospitalInspections.org

Based on the kitchen observational tour with the administrative dietitian (employee #6), review of policies/procedures and food code guidelines and interview, it was determined that the facility failed to operationalize procedures to ensure that appropriate concentration of chemical are used to sanitize kitchen utensils and trays.

Findings include:

During the kitchen observational tour on 9/29/10 at 9:23 am, the administrative dietitian (employee #6) stated on 9/29/10 at 9:25 am that 3 M Twist ' n Fill Cleaning Dispenser is used to sanitize utensils and trays. She also stated that the correct proportion of sanitizing agent is mixed with water to make the solution an appropriate concentration. She also stated that there is no procedure used to test the appropriate concentration of sanitizing agent in the water. The facility failed to ensure that sanitizing procedures are followed for the disinfection of utensils and trays according with standards of practice.

Based on tests performed on equipment, review of policies/procedures and observations made during the survey for the physical environment with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2), it was determined that the physical structure and care areas failed to allow staff to provide care in a safe manner ensuring the well being of patients receiving services related to nursing personnel at the emergency room without a key to open the door of the bathroom in the waiting area.

Findings include:

The waiting room bathrooms of the emergency room were visited on 9/29/10 at 9:25 am with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2) and provided evidence that there are two patient bathrooms (male and female). The emergency call system of the male bathroom was activated and the door was locked from the inside, nursing personnel arrived, however they did not have a key to open the door. The Physical Plant Manager (employee #2) identified the keys for these bathrooms and made various copies and supplied them to different nursing personnel on 9/29/10 at 10:00 am. In-service training related to the use of these keys for all personnel from all shifts is required along with periodic testing for compliance.

Based on tests to equipment and observations made during the survey for Life Safety from fire with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2), it was determined that the facility does not meet some applicable provision of the 2000 edition of Life Safety Code of the NFPA 101.

Findings include:

The Life Safety from Fire survey was performed on 9/29/10 and 9/30/10 from 8:00 am till 4:00 pm with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2); for deficiencies related to Life Safety from fire (form 2786R) please see tags with letter K on the 2567 form (K0018, K0048, K0050, K0051, K0052, K0055, K0069, K0130 and K0144).

Based on observations and tests made during the survey for the physical environment with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2), it was determined that the structure of this facility is not maintained to protect and safe guard supplies and equipment to ensure safety and quality related to non functioning nursing call systems for beds #1 and #2 of the pre-induction area, the housekeeping closet located in the hallway near the pre-induction room was found with biohazardous and regular trash containers and the dirty linen closet on the second floor contained bags of dirty and contaminated linen on shelves instead of in closed containers.

Findings include:

1. The operating room department was visited on 9/29/10 from 1:30 pm till 2:30 pm with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2) and the following was determined:
a. The nursing call system for beds #1 and #2 of the pre-induction area did not work when tested.
b. The housekeeping closet located in the hallway near the pre-induction room was found with biohazardous and regular trash containers. These materials can not share the same space of housekeeping equipment due to the risk of cross contamination.

2. Observations of the dirty linen closet on the second floor on 9/30/10 at 8:45 am with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2) provided evidence that bags of dirty and contaminated linen are placed on shelves and not in closed containers.

Based on tests performed on equipment and observations made during the survey for the physical environment with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2), it was determined that this facility's physical structure is not designed in accordance with Federal and State laws related with handicapped toilets (male and female) in the waiting area of the emergency room without mirrors and the hand sinks in these bathrooms have drainage tubes that extend beyond 6 inches from the wall, a push pad is needed on both sides of the main entrance door that automatically opens the door leafs to allow persons with impediments or with upper body weakness to access this entrance, the designated handicapped parking spaces located near the ambulance entrance of the emergency room is needed closer to the entrance, the emergency room waiting area is also used as a waiting area for other areas of the hospital, there is no designated decontamination area, the walls that separate both triage rooms from the outside passage way does not finish at the ceiling which does not ensure auditory privacy, the morgue does not have housekeeping facilities or a handsink with soap and paper dispensers, the respiratory therapy room in the emergency room was found with little space between lounge chairs and no curtains between lounge chairs, the dirty utility room used to disinfect ventilators was found with Cidex OPA without a portable hood or other ventilation system and no spill kit, housekeeping closets located at the emergency room, maternity ward and two in the operating room department do not have floor sinks or air extractors and mop hangers, the operating room department is not properly designed and maintained and some bathrooms have see through plastic shower curtains.

Findings include:

1. The handicapped toilets (male and female) in the waiting area of the emergency room were observed and inspected on 9/29/10 at 9:20 am with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2) and provided evidence that they do not have mirrors above the hand sinks and the drainage tubes of the hand sinks extended beyond 6 inches from the wall which can harm the legs of persons in wheel chairs when they access these hand sinks. Section 4.19 "Lavatories and Mirrors" specifies the minimum requirements of the "Americans with Disabilities Act" (Ley ADA).

2. The main entrance of the hospital is also the designated handicapped entrance and emergency room waiting room entrance and was observed on 9/29/10 at 9:15 am with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2). This entrance provided evidence that this door does not have a push pad on both sides of the door that automatically opens the doors to allow persons with impediments or with upper body weakness to access this entrance without having to swing the doors open manually. The push pad must have the international symbol of accessibility on it to clearly identify it for handicapped use and must be located in a position that when activated, the door will not hit the person pushing the pad.

3. During observations of the designated handicapped parking spaces located near the ambulance entrance of the emergency room on 9/29/10 at 10:10 am with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2), it was determined that patients or visitors have to go up an incline from these parking spaces. Handicapped parking shall be located at the shortest route of travel and along a smoothly paved surface to facilitate access and to minimize the effort needed by handicapped persons.

4. The emergency room waiting area was visited on 9/29/10 at 9:15 am with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2). The entrance of this emergency room waiting area is also the main entrance of the hospital and was also used by patients waiting to be called to other areas of the hospital. The emergency room waiting area requires special consideration for patients/visitors needs related to infection control issues, atmosphere or mood (high traffic area) and to ensure that the triage nurse can identify possible status change of patients when waiting to be called by the physician after the triage process. On 9/29/10 at 10:00 am the facility's Administrator (employee #8), Engineer (employee #3) and Physical Plant Manager (employee #2) instructed personnel to direct/assist patients/visitors to the specific waiting areas related to their visit and to only allow patients/visitors of the emergency room access to the emergency room waiting area. The facility must establish in-service training for all personnel and compliance must be periodically monitored and documented.

5. The emergency room was visited on 9/29/10 at 9:35 am with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2) and provided evidence that there is no designated decontamination area, according with Guidelines for Design and Construction of Health Care facilities (GDCHCF) chapter 2.1, section 5.1.3.7, number 5 and A5.1.3.7(5). This area should measure at least 80 square feet, there needs to be at least two hand held shower heads, the walls, floor and ceiling need to be non-porous (for cleaning) there needs to be an outside door to enter this room and there needs to be a water drain trap to collect the used water. If the facility determines to use an external area for this purpose, it needs to be located within 150 feet from the ambulance entrance, there are water and electrical outlets, the area has to be well lighted and the paved ground needs to be marked off in yellow paint with the word "Decon".

6. The triage area of the emergency room was visited on 9/29/10 at 9:35 am with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2) and provided evidence that there are two triage rooms located near the waiting area. The triage rooms are located near the waiting area and in front of both triage rooms separated by a passage way that leads to the entrance of the observation area are two emergency room registration windows. However, the walls that separate both triage rooms from the passage way does not finish at the ceiling (there is approximately a three foot open space along these walls). This opening does not protect patients during interviews and physical evaluations related to auditory privacy.

7. The morgue was visited on 9/29/10 at 11:45 am with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2) and provided evidence that it does not have housekeeping facilities to ensure that spills can be cleaned appropriately and that the area is cleaned after use and does not have a handsink with soap and paper dispensers.

8. The hospital's emergency room was visited on 9/29/10 at 10:00 am with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2) and provided evidence that there are four wall oxygen outlets valves that are in a room that is used to provide respiratory therapy to patients. The four oxygen outlets were placed side by side with little space between them and no curtains were found between the lounge chairs. In order to provide emergency treatment to a patient at least four feet between lounge chairs is needed to accommodate emergency staff and equipment and the curtains are needed to provide privacy during treatment.

9. The dirty utility room used to disinfect ventilators was visited on 9/29/10 at 11:50 am with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2) and provided evidence that they are using Cidex OPA. However this room does not have a portable hood or other ventilation system as suggested by the manufacturers' recommendations, the solution is to be used in a well-ventilated area and in closed containers with tight fitting lids, and the user must use gloves, eye protection and fluid-resistant gowns. The use of Cidex OPA should be in an area that is ventilated with a local exhaust hood which contains a filter media. Also, no evidence was provided that this area has a spill kit to deal with this solution if it spills on the floor.

10. The housekeeping closets located at the emergency room, maternity ward and two in the operating room department were visited on 9/29/10 from 9:35 am and 1:45 pm with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2). These housekeeping closets do not have floor sinks or air extractors and mop hangers are needed to allow mops to air dry above the floor sinks.

11. The operating room department was visited on 9/29/10 from 1:30 pm till 2:30 pm with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2) and the following was determined:
a. The bathroom of the pre-induction area used by patients to change into surgical gowns did not have a bench or seat to sit on to facilitate clothes changing.
b. The phase II area does not have a curtain to separate the two lounge chairs and does not have a desk for a nurse to write her notes and the position of the desk must allow the nurse full visibility of the patients.
c. Observations made during the initial tour provided evidence that the operating room department (dressing room-street clothes to operating room attire, pre-induction room, surgical area and recovery room) are not divided into different designated areas (unrestricted, semi-restricted and restricted) with signs at each area indicating the surgical attire required.
d. The facility places large amounts of supplies on open shelves and tables in operating suites #1 and #2 which does not ensure infection control standards from patient to patient (from different procedures). Cabinets with doors to protect and store sterile supplies within operating suites #1 and #2 should be used when storing supplies within the suites.
e. A microwave is used to warm I.V solutions given to patients, a warmer must be used to ensure temperature consistency.
f. A pail dedicated for contaminated cases was not found at the operating room department.
g. Cidex OPA is used in the operating room department however a spill kit was not found.


15885


12. During the observational tour of the facility with the Infection Control Officer on 9/29/10 from 3:00 pm through 4:30 pm, patient's rooms were visited. Clear (see through) shower curtains were found in patient's bathrooms of the following rooms: #209, #211, #215, #216, #217, #219 and #223. In the event that a patient is in the shower and the door is opened, the patient will be completely exposed to persons in the room.

Based on observations made during the survey for the physical environment with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2), it was determined that the physical structure and care areas failed to provide proper ventilation in the emergency rooms' triage area and observation areas, they are not equipped with an air disinfection system.

Findings include:

The emergency room was visited with the facility's Engineer (employee #3) and Physical Plant Manager (employee #2) on 9/29/10 from 9:15 am till 11:25 am and provided evidence that the triage area and the observation area of the emergency room are not equipped with an air disinfection system (for example: Ultraviolet lights). According to the "Guidelines for Design and Construction of Health Care Facilities" (GDCHCF) the triage area is the point of entry of undiagnosed and untreated airborne infections and should be designed and ventilated to reduce exposure of staff, patients and families to airborne infectious diseases. Through the facility's infection control program, determinations must be made related to general ventilation and air disinfection similar to inpatient requirements for airborne infection isolation rooms according to the CDC "Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health Care Facilities". The observation area is another area to provide protection with an air disinfection system. The facility already has an Ultraviolet lamp in the emergency room waiting area, however they failed to demonstrate maintenance and cleaning documentation.

Based on the observational tour of the facility with the infection control officer (employee #9), review of policies/procedures and interviews, it was determined that the facility failed to promote sanitary and safe care through its infection control program in the emergency room, medicine unit, delivery room department and nursery department related to improper infection control procedures and failed to follow infection control standards of practice.

Findings include:

1. The following was observed in the emergency room on 9/29/10 from 9:15 am till 3:00 pm related to infection control procedures with the emergency room supervisor (employee #1):

a. The examination bed in examination room #5 in the emergency room was observed on 9/29/10 at 10:35 am and provided evidence that the bed used for Ob/Gyn examinations was ripped.

b. Two vials of Humulin 70/30 and Novolin N were observed with the date opened of 6/24/10 and 8/5/10 and were found in the refrigerator of the medication room on 9/29/10 at 10:30 am available for patients' use. The multi-use vials exceeded 28 days opened, recommendations from the manufacturer suggests that multi-use vials are to be discarded after 28 days from the day that they are opened.

c. The housekeeping cart located in the hallway of the emergency room was observed on 9/29/10 at 10:00 am unattended with the following chemical solutions on the top of the cart accessible to non-authorized person: Horky 814 disinfectant solution, Tubercucide spray disinfectant and super Sobb glass cleaner.

d. The housekeeping closet located at the emergency room on 9/29/10 at 9:45 am was visited and provided evidence that 4 rolls of toilet paper and 5 rolls of hand paper were placed on a shelf without a protective plastic cover exposing them to the environment.

2. The following was observed on the second floor (medicine, Ob/Gyn, labor room, surgery, nursery and pediatric area) on 9/29/10 and 9/30/10 from 9:15 am till 4:30 pm related to infection control procedures with the infection Control Officer (ICO) (employee #9):

a. During the observational tour of the second floor with the infection control officer (employee #9), beds in rooms #209 through #215 were found on 9/29/10 from 3:00 pm through 4:15 pm with clean linen (fitted and flat sheets) on beds that were not assigned to patients. Interview with the ICO on 9/29/10 at 3:30 pm provided evidence that they prepare beds with linen in advance of the admissions to the wards. The facility failed to ensure that bed linens are not prepared in advanced to ensure that infection control procedures are followed to reduce possible causes of cross contamination.

b. Two plastic manual Ambu bags were observed hanging on the cardiorespiratory cart in the medicine ward on 9/29/10 at 3:45 pm. The Ambu bags were observed in plastic bags, however the bags were directly touching the floor.

c. Three re-filled bottles (4 ounces) of Betadine solution were observed on 9/29/10 at 3:50 pm in the storage room without expiration dates, lot numbers and the personnel who prepared the solutions.

3. The following was observed in the delivery labor room department (DLR) on 9/30/10 from 9:30 am through 9:45 am related to infection control procedures:

a. During observations of the DLR department on 9/30/10 at 9:30 am the Ob/Gyn physician (employee #10) was observed walking in a common non-restricted hallway near the ante-delivery and the delivery room with his street clothes. According to Policies and Procedures (P/P) as stated by the ICO on 9/30/10 at 9:45 am, personnel can not walk in these hallways without using protective gowns over their street clothes and shoe covers.

b. The delivery labor room was observed without a separation door between the nursing and post-partum area on 9/30/10 at 11:30 am. The lack of a separation door between these two areas does not ensure infection control standards related to personnel traffic. P/P reviewed on 9/30/10 at 11:35 am states that personnel are not allowed in these areas without proper protective gowns (please cross reference deficiency 3a above).


15884


4. The following was observed in the medicine ward on 9/29/10 from 9:47 am till 11:00 am related to infection control procedures:

a. A medication cart was observed located inside room #223. This practice promote cross contamination by moving the cart inside the rooms from the hallways and others patient rooms.

b. One enteral nutrition machine was observed stored inside a cabinet at the medicine ward. The administrative dietitian (employee #5) stated during an interview on 9/29/10 at 9:55 am that after patients are discontinued from enteral nutrition machines, personnel disinfect the machines and store them in this room. In the same room two crash carts and an EKG machine were observed. This practice promotes cross contamination of the enteral nutrition machine with other equipment used on patients.

Based on the review of the policies/procedures manual with the emergency room nursing supervisor (employee #1), it was determined that the facility failed to comply with procedures related to the integration or coordination between the emergency room and other departments.

Findings include:

1. The following was determined related to the emergency department's policies/procedures reviewed on 9/29/10 from 1:00 pm till 2:00 pm:

a. No evidence was found of procedures related to the integration and coordination between the Emergency Department with the other departments of the hospital such as: the delivery room, surgical services, laboratory, admission department, diet services and the radiology department. The hospital must be able to demonstrate how the hospital's other departments provide emergency patients the care and services needed within a safe environment, within a timely manner and with appropriate/available personnel.

Based on ten medical records reviewed (R.R), review of the policies/procedures manual and the observational tour with the emergency room (E.R) nursing supervisor (employee #1) and interview, it was determined that the facility failed to have a plan or assignments for all specific tasks in the event of an emergency, the triage room does not have visibility of the patients that arrive at the emergency room for interviews and to categorize the patients, reassessing patient's pain levels after the initial assessment, documenting risks and benefits related to condition at the moment of the transfer for (R.R #21 through #25 and #31 through #35) and the emergency room failed to follow infection control standards to prevent cross contamination.

Findings include:

1. The following was observed during the visit of the emergency department on 9/29/10 from 9:15 am till 3:00 pm:

a. No evidence was found on 9/29/10 at 11:00 am that emergency personnel have a plan or assignments for all specific tasks in the event of an emergency. All personnel trained related to emergency procedures must be instructed related to their assignments and periodically tested for its implementation and the assignment must be posted for review by staff.

2. During the Emergency Room (ER) visit on 9/29/10 at 9:45 am the waiting room was found full of patients and a computer was found near the triage entrance. The computer is used by patients to register their visit related to the order in which they arrived and the hour as stated by the ER supervisor (employee #1) on 9/29/10 at 9:50 am. The triage nurse in the triage room located near the waiting area did not have visibility of the patients that arrive at the emergency room for interviews and to categorize the patients. The triage room was observed with a computer that was turned on while the nurse evaluated a patient. During the triage process the nurse did not have access to a computer screen to evaluate the names of the patients in order of their arrival at the emergency room related to their condition before the triage process. The ER supervisor (employee #1) stated during an interview on 9/29/10 at 10:10 am that the triage nurse calls the patients in the order that they appear on the computer for triage and not related to the condition of the patient at the moment that they arrive at the emergency room. Some of these patient's records were reviewed after the emergency room triage process and the following was determined:

a. R.R #21 is a 39 years old female who visited the emergency room on 9/29/10 at 9:02 am with Ureterolitisis and Urinary Tract Infection. The patient was observed sitting in the waiting area and she stated on 9/29/10 at 9:25 am that she had back pain during the night. The record was reviewed on 9/29/10 at 2:00 pm and provided evidence that the triage was performed at 9:02 am and the patient was categorized as "urgent" with the pain assessment recorded between 5-6, however she was sent to the waiting area. The ER physician evaluates the patient related to Ureterolitiasis and Urinary Tract Infection and ordered treatment at 10:30 am. It is not until 1:30 pm that an ER registered nurse takes the order for renal sonogram and laboratory samples. As of 2:15 pm the patient was still in the waiting area with the same pain intensity. The facility failed to ensure that triage screening and categorization are performed according to the patient's needs as they arrive at the ER and failed to ensure that treatment orders are carried out within a reasonable time frame.

b. R.R #22 is a 45 years old female who visited the emergency room on 9/29/10 at 9:39 am with abdominal pain. The patient was observed sitting in the triage area on 9/29/10 at 9:55 am and stated that she had pain the entire night. The record was reviewed on 9/29/10 at 2:15 pm and provided evidence that the patient was triaged at 9:39 am and categorized as "urgent" with a pain assessment recorded between 9-10, however she was sent to the waiting area. The ER physician evaluates the patient related to Abdominal Pain and orders treatment at 10:00 am. It is not until 11:10 am that an ER registered nurse takes the order for Demerol 50 mg, Vistaril 50 mg intramuscular and Abdominal Sonogram. As of 2:30 pm the patient was in the observation area, but nursing personnel did not perform a re-evaluation of her pain level. The facility failed to ensure that triage screening and categorization are performed according to the patient's needs as they arrive at the ER and failed to ensure that treatment orders are carried out within a reasonable time frame.

c. R.R #24 is a 77 years old male who visited the emergency room on 9/29/10 at 9:30 am with left forearm trauma. The patient was observed sitting in the waiting area accompanied by his wife. He stated on 9/29/10 at 9:40 am that he fell two days ago and he has a lot of hand pain and the patient was not triaged. The patient was taken to the observation area after his condition was identified. The record was reviewed on 9/29/10 at 2:45 pm and provided evidence that the patient was triage and categorized as "urgent" with a pain assessment recorded between 7-8. The ER physician evaluates the patient related to the forearm trauma and orders treatment at 10:30 am. It is not until 11:30 am that an ER registered nurse takes the order for Nubain 10 mg intramuscular and regular insulin 8 units and administers treatment. The facility failed to ensure that triage screening and categorization are performed according to the patient's needs as they arrive at the ER and failed to ensure that treatment orders are carried out within a reasonable time frame.

d. R.R #35 is an 81 years old male who visited the emergency room on 9/30/10 at 4:59 am with bilateral inguinal hemorrhage. The patient was observed in the observation area accompanied by his daughter on 9/30/10 from 8:30 am through 3:10 pm and he stated that he had pain the entire night and could only urinate a small amount. The patient was observed with a foley catheter with the expose tubing and collection bag and provided evidence that the urine was a dark red color. The record was reviewed on 9/30/10 at 3:20 pm and provided evidence that the patient was triaged at 4:59 am and categorized as "urgent", however he was sent to the waiting area. The ER physician evaluates the patient and orders treatment at 7:10 am. It is not until 8:30 am that an ER registered nurse takes the order for X-ray, laboratory samples, renal sonogram and foley catheter. The laboratory results from the emergency room services provided evidence that the patient's hemoglobin was: 10.0 mg/ml, 7,000 white blood cell and loaded red blood cells in urine. The facility failed to ensure that triage screening and categorization are performed according to the patient's needs as they arrive at the ER and failed to ensure that treatment orders are carried out within a reasonable time frame.

3. Eight out of ten active and closed records reviewed on 9/29/10 and 9/30/10 from 1:00 pm through 3:00 pm provided evidence that at the moment that the triage nurse performs her assessment and categorizes the patient as "urgent", the patient is sent to the waiting area of the ER instead of attending the patient within the time frame established by the facility (R.R
#22, #23, #25 and #31 through #35).

4. No evidence was found on 9/29/10 from 1:00 pm till 3:00 pm that emergency room personnel are reassessing patient's pain levels after the initial assessment or duration of pain management for patients' seen at the triage of the emergency room for five out of ten records reviewed (R.R #21, #22, #31, #32 and #34).

5. Three out of four closed clinical records were reviewed for transfer procedures on 9/30/10 from 2:30 pm till 3:30 pm for emergency room services and provided evidence that the physician's risks for transfer was "unexpected events", instead of a risk related to the health condition (R.R #31, #32 and #33). R.R #32 provided evidence that the physician documented none as the benefit related to the patients' condition at the moment of the transfer to another facility. The patients were evaluated and stabilized with diagnosis of Left Arm Fracture, Left Thigh Infected Wound and Synovitis of a Right Hand after the initial evaluation of the emergency room visit.

6. The following was observed in the emergency room on 9/29/10 from 9:15 am till 3:00 pm related to infection control procedures:

a. The examination bed in examination room #5 in the emergency room was observed on 9/29/10 at 10:35 am and provided evidence that the bed used for Ob/Gyn examinations was ripped.

b. Two vials of Humulin 70/30 and Novolin N were observed with the date opened of 6/24/10 and 8/5/10 and were found in the refrigerator of the medication room on 9/29/10 at 10:30 am available for patients' use. The multi-use vials exceeded 28 days opened, recommendations from the manufacturer suggests that multi-use vials are to be discarded after 28 days from the day that they are opened.

c. The housekeeping cart located in the hallway of the emergency room was observed on 9/29/10 at 10:00 am unattended with the following chemical solutions on the top of the cart accessible to non-authorized person: Horky 814 disinfectant solution, Tubercucide spray disinfectant and super Sobb glass cleaner.

d. The housekeeping closet located at the emergency room on 9/29/10 at 9:45 am was visited and provided evidence that 4 rolls of toilet paper and 5 rolls of hand paper were placed on a shelf without a protective plastic cover exposing them to the environment.