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Based on observation and interview, the facility failed to assure a sanitary environment. The failed practice did not assure an environment which was free from contamination and had the potential to affect all patients, staff and visitors in the facility. Findings follow:

A. A tour of the facility was conducted on 12/14/11 from 1040 to 1155 with the Director of Patient Care Services which revealed the following:
1. Patient Room #224 (semi-private room): stained mattresses, Bed A and Bed B, grime and hair in corners of bathroom, air conditioning unit cover soiled and staining inside closet for Bed A.
2. Clean Storage Room on Medical/Surgical Unit: one case of saline on floor, dust on IV pole, dust on oxygen regulators, dust on patient scale and dust on vital signs monitor.
3. Soiled Utility Room on Medical/Surgical Unit: storage of clean " Redibath " perineal pads and hazardous waste container without lid.
4. Patient Room #231 (semi-private room): wooden laminate was rippled from water damage, tape holding baseboards to wall, separated and cracked/broken baseboards in the bathroom next to shower, rust on IV pole and a ceiling tile hanging.
5. Medical Surgical Unit Corridor: dust on top of Omnicell and dust on top of crash cart.
6. East Station Patient Nutrition Room: rodent feces was found in six of six drawers, evidence of rodents eating condiment packages and packages of crackers, hardened (old) food on top of microwave covered in aluminum foil, various food containers and staff belongings (purse) in cabinets, rust and mouse trap under sink and wall board over sink cracked.
7. Medical Surgical Unit Tub Room: large clear bag with used aluminum cans, broken vital signs monitor, sterile IV fluids, blankets, orthopedic equipment (crutches, walkers, wheelchairs, over bed frame traction devices) and broken ceramic tile on corner of bathtub.
8. Intensive Care Unit Room 1: dust on top of light fixture and rust on IV pole.
9. Intensive Care Unit: dust on crash cart and plastic container to catch water from leak under sink in cabinet across from Nurses ' Station.

B. Findings were verified with the Director of Patient Care Services during the tour.






Based on review of the facility ' s, Infection Control/Environmental Services document, Environmental Cleaning Log, East Station Clean Utility/Nourishment Room Daily Check Log, Environmental Services Manager Performance Criteria document and interview, the facility failed to assure maintenance of a sanitary environment. The lack of a sanitary environment had the potential to affect all patients, staff and visitors at the facility. Findings follow:

A. Review of the East Station Clean Utility/Nourishment Room Daily Checks document for December 2011, revealed a checklist completed by the Dietician for drawer #2. Observation of drawer #2 revealed rodent feces and wrapped sets of plastic utensils on the tour conducted December 14, 2011 from 1040 to 1155. The Director of Patient Care Services confirmed the above findings.

B. During interview on 12/15/11 at 1010 with the Physical Environment Manager, he noted East Station Clean Utility/Nourishment Room was identified on the Environmental Cleaning Log as Clean Utilities. Review of the Environmental Cleaning Log from January 5, 2011 through January 31, 2011, June 1, 2011 through June 30, 2011 and November 1, 2011 through November 11, 2011 did not have documented evidence that the East Station Clean Utility/Nourishment Room had been cleaned by the Environmental Services staff. Findings were verified by the Physical Environment Manager during an interview on 12/15/11 at 1010.

C. Review of the Infection Control/Environmental Services document revealed Env. (Environmental) Services personnel should wipe with disinfectant solution ... IV poles, pumps ... floor will be wet mopped with a disinfectant solution ... " . The Physical Environment Manager confirmed the document during interview on 12/15/11 at 1010. Review of the Environmental Services Manager Performance Criteria revealed responsibilities included making daily rounds to assure that Environmental Services personnel were performing required duties and to assure that proper Environmental Services procedures were being met. On interview with the Physical Environment Manager on 12/15/11 at 1010 revealed daily rounds were not conducted as required.

Based on observation, review of the facility ' s Infection Control Policy, Infection Control Surveillance document, Infection Control Inservice Training document, Infection Control Audit and interview, the facility failed to assure infection control practices which included surveillance and training, was undertaken by the Infection Control Nurse. The failed practice did not assure the facility was inspected for sanitary conditions or that staff were trained in infection control and had the potential to affect all patients, staff and visitors in the facility. Findings follow:

A. Review of the facility ' s Infection Control Policy revealed, " Infection Control related inservice training will be offered frequently, to all departments of the hospital. These inservices shall be presented at least every quarter, and more often if necessary " . The facility did not present documentation or evidence of quarterly inservice training.

B. On 12/15/11 at 1000, the Quality Improvement/Infection Control Nurse presented an Infection Control Audit tool which was blank.

C. Review of the Infection Control Surveillance document revealed, " Infection control inspection of specific departments will be made periodically. This procedure will be done without the knowledge of said department and all deficiencies will be addressed with the department manager " . The facility did not present documentation or evidence of surveillance activities.

D. Findings were verified with the Infection Control Nurse 12/15/11 at 1000.