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Based on observation, policy review, and interview, it was determined that the facility failed to provide a sanitary environment in all areas of the hospital.


Findings were:


"OSHA/Blood borne Pathogen Regulations Policy #138-030-060 " stated in part " The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner."


Facility Policy titled, "Care and Cleaning of Surgical Instruments" stated in part "Ring-handled instruments should be secured in a manner that retains them in an open position for sterilization."

Facility Policy titled, "Policy on Steam Sterilization" stated in part, "Procedure A. Clean items to be sterilized to eliminate all decontaminate prior to sterilization. Ensure all hinges are unhinged during decontamination ...
G. Leave all hinged instruments unhinged during sterilization."

Facility Policy titled, "Terminal Cleaning and Sanitation" stated in part,
"5.0 Procedure:
5.1 Clean high-touch surfaces. ES [Environmental Services] staff should begin by cleaning high-touch surfaces with an EPA-registered sporicidal disinfectant. High-touch areas include door handles and knobs, light switches, call buttons, tray tables, bedrails and phones.
5.0 Dust the room. Staff should follow their facility guidelines for a cleaning path, such as cleaning clockwise, top to bottom. They should start with overhead lights. Next, they should damp dust the television, television stand, lights, bed frame, mattress covers, pillows and blood pressure cuffs and remove unused linen and other such items."

Facility Policy titled, "General Cleaning Precautions" stated in part,
"3.0 Policy: 3.1 All patient and non-patient rooms shall be thoroughly cleaned and/or disinfected, keeping in mind Standard Precautions and infection control."

Facility Policy titled, "Laundry Cleaning Area" stated in part, "3.0 Policy: 3.1 The GRMC [Graham Regional Medical Center] laundry area will be kept clean and in neat order."

Facility Document titled, "Infection Prevention and Control Plan" stated in part, "5. Procedures
5.4 Program Elements:
5.4.8. Ensure that the environment is sanitary in all areas and units.
5.4.9. Ensure that the floors and carpets are free from tears, stains and are maintained professionally on a scheduled maintenance."

When asked if there was a policy related to environmental surveillance, staff #1 was unable to provide one. Facility document titled, "Hospital Wide Cleaning and Preventive Maintenance" was provided with "Environmental Rounds" and "floors" check-lists that did not include kitchen and laundry areas.

Facility document titled, "Patient Rights" stated in part, "Considerate and Respectful Care: To receive ethical, high-quality, safe and professional care without discrimination ...
Access to Services ... to safe, secure and sanitary accommodation and a nourishing, well balanced and varied diet ..."

The following was observed on a tour of the facility on 6/20/16:
ER medication room the following sterilized instruments were found closed:
· Hemostats dated 3/3/16
· Nasal speculum dated 6/29/16
· Three forceps dated 3/3/16
· Medical scissors without a date
· Hemostat dated 2/10/16
Cardiac room in the ER:
· Dust build up on monitor arm
· Dust build up on oscillating fan
· Crack in the floor by doorway
Trauma room in the ER:
· Dust build up on back wall unit
· Dust build up on computer and desk
Kitchen:
· Dirty potholder was being used to pull out serving plates from the warmer
· Refrigerator glass door was dirty
· Refrigerator shelves were rusty on the corners
· Grease on top of refrigerator
· Bottom shelf of a side table used to store pots and pans was dirty and rusty
· Rack used for drying pots and pans was dirty
· Overhead vent for stove was greasy and dirty
· Overhead hanging rack for storage of pots and utensils had paint chipping off and was rusty; this was directly over the area where food was being prepared
· Tape used to post instructions on plate warmer was dirty and would be impossible to clean
· Phase butter flavor with no opened date
· Two packages of hamburger buns were opened with no date
· One tortilla package opened with no date
· Three bags of biscuits were opened with no dates
· Two boxes of half gallon ice cream opened with no dates
· Four boxes of opened popsicles with no dates
· Container filled with individually wrapped rice crispy treats covered with freezer burn and no dates
· Two Italian ice cream boxes opened with no dates
· Steri-strips used to check bleach and dishwasher solutions were expired on 12/13/15
· Eyewash station sink with dirt

The following was observed on a tour of the facility on 6/21/16:
Med-Surg [Medical-Surgical] room 131:
· Moisture marks indicating the mattress was not dried completely after cleaning
· Chipped paint on the door, making it impossible to fully clean
Med-Surge room 124:
· Chips in the door
· Dust build-up on the window sill
Pre-Op [operation] holding room 3:
· Paint chipping off end of bed
· Paint chipping off IV [intravenous] pole of the bed
Pre-Op holding room 5:
· Chip on corner of counter
· Paint chipping off IV pole on the bed
Recovery room:
· Rust on bed
· Paint chipping off of table and IV pole on the bed

The above was confirmed in an interview with staff #1 on the afternoon of 6/20/16 and the morning of 6/21/16.


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Based on review of documents, observation, and interviews with facility staff, the facility failed to maintain equipment to ensure an acceptable level of safety and well-being as the condition of the physical plant was a potential hazard to staff, patients, and the public.

Findings included:

Facility Policy titled, "Laundry Cleaning Area" stated in part, "3.0 Policy: 3.1 The GRMC [Graham Regional Medical Center] laundry area will be kept clean and in neat order."

When asked if there was a policy related to environmental surveillance, staff #1 was unable to provide one. Facility document titled, "Hospital Wide Cleaning and Preventive Maintenance" was provided with "Environmental Rounds" and "floors" check-lists that did not include kitchen and laundry areas.
The check-list titled, "Floors" stated in part, "Floors should be stripped and waxed q [every] six months but buffed at least three times weekly. If they are not buffed, they will not hold [sic]"
A check-list titled, "Wall Surveillance" stated in part, "all walls are to be free of holes and chipped paint. All walls shall be checked on a quarterly basis and reported to IPC [Infection Prevention and Control] and PI [Performance Improvement]."
A check-list titled, "Lights" stated in part, "All light fixtures shall be free of bugs and debris. This shall be reported to IPC and PI on a quarterly basis."


Facility document titled, "Patient Rights" stated in part, "Considerate and Respectful Care: To receive ethical, high-quality, safe and professional care without discrimination ...
Access to Services ... to safe, secure and sanitary accommodation and a nourishing, well balanced and varied diet ..."


On a tour of the facility on 6/20/16, a crack in the floor by the doorway was observed in the cardiac room in the emergency department.

The following was observed on a tour of the facility on 6/21/16:
Med-Surg [Medical-Surgical] room 131:
· Chipped paint on the door, making it impossible to fully clean
Med-Surge room 124:
· Chips in the door
Pre-Op holding room 5:
· Chip on corner of counter
Main hallway:
· Bubbling and cracking in middle of the floor in front of dining room
· Bubbling on floor in front of radiology waiting room entrance
Laundry room:
· Paint chipping off on window sill above where clean linens are folded
· Two overhead lights with visible dirt
· Cracks in exterior wall with outside light shining in
· Three unsealed pipes on ceiling
· One open hole in ceiling
Exterior door between dining and laundry rooms with light shining through.

The above issues were confirmed in an interview during the tours by staff #1.

Based on policy review, observation, and interview the facility failed to follow their own policies to waste management.

Findings included:

Facility Policy titled, "Medical Waste Management" stated in part, "5.9 Sharps Containers
5.9.1. Sharps waste (blades, needles, knives, broken glass) shall be disposed of in the sharps container. Container shall be filled only to designated level (2/3 full).
5.9.2. When container is 2/3 full, the lid is to be closed tightly, and placed in designated area for pick up by Environmental Services personnel. If designated area is not defined, do not leave container in a public area. Place container in the dirty utility room and contact Environmental Services for removal of container.
5.12 Patient Rooms ...
5.12.4 When sharps containers are filled to designated line (2/3 full), the lid shall be closed tightly and placed in the 'Dirty' utility room for pick up by Environmental Services personnel."

Tour of the facility on 6/20/16 revealed a sharps container that was overflowing in the Cardiac examination room in the emergency department.

The above was confirmed in an interview with staff #1 on the afternoon of 6/20/16.

Based on observation, policy review, and interview, it was determined that the facility failed to provide a sanitary environment in all areas of the hospital.


Findings were:


"OSHA/Blood borne Pathogen Regulations Policy #138-030-060 " stated in part " The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner."


Facility Policy titled, "Care and Cleaning of Surgical Instruments" stated in part "Ring-handled instruments should be secured in a manner that retains them in an open position for sterilization."

Facility Policy titled, "Policy on Steam Sterilization" stated in part, "Procedure A. Clean items to be sterilized to eliminate all decontaminate prior to sterilization. Ensure all hinges are unhinged during decontamination ...
G. Leave all hinged instruments unhinged during sterilization."

Facility Policy titled, "Terminal Cleaning and Sanitation" stated in part,
"5.0 Procedure:
5.1 Clean high-touch surfaces. ES [Environmental Services] staff should begin by cleaning high-touch surfaces with an EPA-registered sporicidal disinfectant. High-touch areas include door handles and knobs, light switches, call buttons, tray tables, bedrails and phones.
5.0 Dust the room. Staff should follow their facility guidelines for a cleaning path, such as cleaning clockwise, top to bottom. They should start with overhead lights. Next, they should damp dust the television, television stand, lights, bed frame, mattress covers, pillows and blood pressure cuffs and remove unused linen and other such items."

Facility Policy titled, "General Cleaning Precautions" stated in part,
"3.0 Policy: 3.1 All patient and non-patient rooms shall be thoroughly cleaned and/or disinfected, keeping in mind Standard Precautions and infection control."

Facility Policy titled, "Laundry Cleaning Area" stated in part, "3.0 Policy: 3.1 The GRMC [Graham Regional Medical Center] laundry area will be kept clean and in neat order."

Facility Document titled, "Infection Prevention and Control Plan" stated in part, "5. Procedures
5.4 Program Elements:
5.4.8. Ensure that the environment is sanitary in all areas and units.
5.4.9. Ensure that the floors and carpets are free from tears, stains and are maintained professionally on a scheduled maintenance."

When asked if there was a policy related to environmental surveillance, staff #1 was unable to provide one. Facility document titled, "Hospital Wide Cleaning and Preventive Maintenance" was provided with "Environmental Rounds" and "floors" check-lists that did not include kitchen and laundry areas.

Facility document titled, "Patient Rights" stated in part, "Considerate and Respectful Care: To receive ethical, high-quality, safe and professional care without discrimination ...
Access to Services ... to safe, secure and sanitary accommodation and a nourishing, well balanced and varied diet ..."

The following was observed on a tour of the facility on 6/20/16:
ER medication room the following sterilized instruments were found closed:
· Hemostats dated 3/3/16
· Nasal speculum dated 6/29/16
· Three forceps dated 3/3/16
· Medical scissors without a date
· Hemostat dated 2/10/16
Cardiac room in the ER:
· Dust build up on monitor arm
· Dust build up on oscillating fan
· Crack in the floor by doorway
Trauma room in the ER:
· Dust build up on back wall unit
· Dust build up on computer and desk
Kitchen:
· Dirty potholder was being used to pull out serving plates from the warmer
· Refrigerator glass door was dirty
· Refrigerator shelves were rusty on the corners
· Grease on top of refrigerator
· Bottom shelf of a side table used to store pots and pans was dirty and rusty
· Rack used for drying pots and pans was dirty
· Overhead vent for stove was greasy and dirty
· Overhead hanging rack for storage of pots and utensils had paint chipping off and was rusty; this was directly over the area where food was being prepared
· Tape used to post instructions on plate warmer was dirty and would be impossible to clean
· Phase butter flavor with no opened date
· Two packages of hamburger buns were opened with no date
· One tortilla package opened with no date
· Three bags of biscuits were opened with no dates
· Two boxes of half gallon ice cream opened with no dates
· Four boxes of opened popsicles with no dates
· Container filled with individually wrapped rice crispy treats covered with freezer burn and no dates
· Two Italian ice cream boxes opened with no dates
· Steri-strips used to check bleach and dishwasher solutions were expired on 12/13/15
· Eyewash station sink with dirt

The following was observed on a tour of the facility on 6/21/16:
Med-Surg [Medical-Surgical] room 131:
· Moisture marks indicating the mattress was not dried completely after cleaning
· Chipped paint on the door, making it impossible to fully clean
Med-Surge room 124:
· Chips in the door
· Dust build-up on the window sill
Pre-Op [operation] holding room 3:
· Paint chipping off end of bed
· Paint chipping off IV [intravenous] pole of the bed
Pre-Op holding room 5:
· Chip on corner of counter
· Paint chipping off IV pole on the bed
Recovery room:
· Rust on bed
· Paint chipping off of table and IV pole on the bed

The above was confirmed in an interview with staff #1 on the afternoon of 6/20/16 and the morning of 6/21/16.


36594