HospitalInspections.org

Based on a review of facility documentation, facility tour, and employee interviews (EMP), it was determined that the facility failed to maintain a clean and sanitary environment that is free of dust and debris in the Emergency Department.

Findings include:

Review, at approximately 1:18 PM on October 3, 2022, of facility policy HS-FM0240-PRO "Patient Room Cleaning Procedure," dated July 28, 2021, revealed, "... 8. High dust: a. Using the long handled duster, move clockwise around the room, high dust the tops of items on the walls that are at or above your shoulder height. Note: Follow procedure on high dusting. B. Include items such as pictures, mirrors, bulletin boards, white boards, vents, tops of cabinets, lights, window and door frames... 10. Disinfect surfaces and high touch areas a. Damp wipe surfaces and high touch areas by moving clockwise around room, cleaning top to bottom and clean to dirty, starting with the patient immediate area. Include e-record keyboard, computer mouse, bedside rails, bed controls, traction bars, nurse call bell/TV remote, telephone, bedside stand, light switches, nurse locator plate, hand sanitizer and holder, over bed table, door knobs/latches, modules and poles. b. Clean trash receptacles last. Allow to air dry before relining...".

A review, at approximately 3:00 PM on October 3, 2022, of the facility's "Infection Prevention & Control Plan CY2022" revealed "I. Purpose: To provide a program incorporating surveillance, prevention, and control of infection for the health and safety of the population we serve in our geographical location....reduce the risk of acquiring and transmitting infections among patients, employees, physicians...IV. Authority and Responsibility...A. Train and educate staff, including medical staff, on IP&C policies, procedures and guidelines including isolation precautions and sanitation techniques....B...3....Make provisions for on-going review and evaluation of asepsis, isolation and sanitation techniques employed to ensure microbiological safety...V...10. Routine Care of the Environment...The Environmental Services...work closely with the IP&C Department to ensure policies are in keeping with healthcare standards for cleanliness and hygiene in the environment...Protocols are in place to promote patient safety using proper cleaning, disinfection, and sterilization techniques...".

A review, at approximately 3:15 PM on October 3, 2022, of facility policy "Patients' Notice and Bill of Rights and Responsibilities", policy number HS-HD-PR-01, dated January 4, 2021, revealed "...Staff and Environment: You have a right to: 1. Receive respectful care given by competent personnel in a setting that: a. is safe and promotes your dignity, positive self-image and comfort ...".

1. During a tour of the facility between approximately 11:15 AM-12:15 PM, on September 28, 2022, a visible accumulation of dust was noted on the surface of the following areas within clean room two of the Emergency Department: on top a pulse ox recycling bin, the overhead vent nearest the pulse ox recycling bin, the top of the television, on the patient communication board, the wall-mounted overbed light, the pull-down over head light, the ledge of the wall boarder and floor baseboard, the overhead light in the bathroom, and the outside ledge of the nurses station closest to room two.

EMP1 confirmed the above findings at the time of tour.

2. A continued tour of the Emergency Department revealed a visibly dirty work surface and keyboard with crumbs and debris on a mobile work station beside the nurse's station. Additional tour of the nurse's station revealed a lower work station cabinet with a large amount of visible accumulated dust and debris.

EMP1 and EMP2 confirmed the findings at the time of the tour.

3. Further tour of the Emergency Department within the area of clean bed 15 revealed the following: a soiled linen bin with a tan-brown colored substance splattered on the lid, a biohazard bin covered with a dried white patchy substance that was easily wiped with a wet cloth, stored bed stirrups with various dust and debris caught within the back side crevices, a floor baseboard ledge that contained a visible white-powdery substance, and a tray table that was sticky to the touch on the underneath surface.

EMP1 & EMP8 confirmed the above findings at the time of tour.