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Based on observation and interview, the facility failed to assure fire safety by having alcohol hand sanitizer dispensers installed directly above spark sources (light switches) in three locations.

Findings include:

During a tour of the operating area on 12/14/2011 at 1:00pm, two alcohol hand sanitizer dispensers were found installed directly above spark sources (light switches). These dispensers were in operating suites 1 and 2. Staff #4 confirmed this finding.

During an interview on 12/14/2011 at 3:30pm in the maintenance office, an alcohol hand sanitizer dispenser was found installed directly above a spark source (light switch). Staff #5 confirmed this finding.

Based on document review and interview the facility failed to insure the Governing Body implemented and monitored policies for 2 of 2 departments (Linen/Laundry and Maintenance).

On 12/17/2011 at 11:00 AM in the conference room the policy and procedures for laundry services were reviewed and revealed the following: there was one policy which indicated the housekeeping department was responsible for distributing laundry to the patient care units.

On 12/17/2011 at 1:00 PM on the patient care unit, a housekeeper was interviewed and was questioned regarding laundry services. She described what she did. When further questioned about a policy the housekeeper stated, "We don't really have a policy we just all know what to do." When asked how new housekeeping employees learn what to to, she replied, "We tell them and make sure they know."

On 12/18/2011 at 10:00 in the conference room, the Director of the Housekeeping/Laundry Services was interviewed. The housekeeping policy manual was reviewed and the director confirmed there were no policies for laundry services, other than the one which indicated housekeeping would distribute laundry to the patient care units. There was no laundry instruction identified in the new employee orientation for housekeeping and laundry services. There was no policy for picking up soiled linen, storage of soiled linen, or transport of soiled linen to the laundry pick up location for the contracted linen service.

Review of the manual entitled, " Policies and Procedures: Maintenance Department, " revealed a title page with spaces for signatures of approval from the following: Board Member, Chief of Staff, Administrator, and Maintenance Manager. There were no signatures or dates in these spaces.

During an interview on 12/15/2011 at 2:15pm in the maintenance office, staff #5 confirmed that the Maintenance Department Policy and Procedure Manual had not been reviewed or approved by the Governing Body. Staff #5 reported that he had been updating the manual. Staff #5 produced an " old " Maintenance Department Policy and Procedure Manual that had been reviewed and approved in May 1997. No manual approved since 1997 could be produced.

During an interview on 12/15/2011 at 2:30pm in the conference room, staff #2 reported that the facility ' s practice was to review and approve policy and procedure manuals on an annual basis.

Based on observation and interview, the facility failed to provide a sanitary environment for storage of its endoscopes. 6 of 6 colonoscopes were found with 4-6 inches of the lumen resting on a towel on the bottom of the scope storage cabinet. The facility also failed to provide a sanitary environment for storage of its surgical supplies. Four wire carts in sterile supply were found with no impermeable barrier on the bottom shelves. The facility also failed to assure a sanitary environment for patients and employees. Unused ( " clean " ) biohazard waste boxes were being stored in the same room with used/soiled biohazard waste boxes. These boxes were then used in patient care areas, leading to possible cross-contamination.

Findings include:

Review of the document, " Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes, " by The Society of Gastroenterology Nurses and Associates revealed the following: " K. STORAGE
1. Hang the endoscope vertically with the distal tip hanging freely in a clean, well-ventilated, dust-free area. "

During a tour of the operating area on 12/14/2011 at 1:00pm, 6 colonoscopes were found with 4-6 inches of the lumen resting on a towel on the bottom of the scope storage cabinet. This could lead to possible scope contamination. Staff #4 confirmed this finding.

During a tour of the operating area on 12/14/2011 at 1:00pm, four wire sterile supply carts were found with no impermeable barrier on the bottom shelves. This could lead to possible contamination of supplies used for surgery. Staff #4 confirmed this finding.

During a facility tour on 12/14/2011 at 3:00pm, it was observed that unused ( " clean " ) biohazard waste boxes were being stored in the same room with used/soiled biohazard waste boxes.

During an interview on 12/14/2011 at 3:30pm in the maintenance hallway, staff #3 confirmed this finding. Staff #3 also reported that the " clean " biohazard waste boxes were taken to patient care areas, where they are used and returned to the soiled biohazard waste area when full.

Based on document review and interview the facility failed to insure the Quality Assurance program included review of services for 1 of 1 departments.

On 12/17/2011 at 11:00 AM in the conference room, the policy and procedures for laundry services were reviewed and revealed the following: there was one policy which indicated the housekeeping department was responsible for distributing laundry to the patient care units.

On 12/17/2011 at 1:00 PM on the patient care unit, a housekeeper was interviewed and was questioned regarding laundry services. She described what she did. When further questioned about a policy the housekeeper stated, "We don't really have a policy we just all know what to do." When asked how new housekeeping employees learn what to to she replied, "We tell them and make sure they know."

On 12/18/2011 at 10:00 in the conference room the Director of the Housekeeping/laundry services was interviewed and the housekeeping policy manual was reviewed and confirmed there were no policies for laundry services other than the one which indicated housekeeping would distribute laundry to the patient care units. There was no laundry instruction identified for the new employee orientation for housekeeping and laundry services. There was no policy for picking up soiled linen, storage or soiled linen or transport of the soiled linen to the laundry pick up location for the contracted linen service.

On 12/18/2011 at 1:30 PM the Quality Assurance meeting minutes were reviewed and no reference to the laundry services or policy review for this department was identified.