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Based on observation, document review, and interview, the hospital failed to ensure a sanitary environment in 3 (rooms 1, 2, and 6) of 3 rooms in the Emergency Department (ED). This violates Texas Administrative Code (TAC) Rule 505.41(g). This Rule states, "(g) Infection control. The hospital shall provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There shall be an active program for the prevention, control, and surveillance of infections and communicable diseases.

A. ED room 1.

B. ED room 2.

C. ED room 6.


Findings

A. ED room 1.

A tour of the ED was conducted on 8/19/2025 after 12:30 PM with Staff #1. Staff #1 was asked if this room was clean and ready to receive patients. Staff #1 stated, "Yes, this room is clean and ready to receive a patient". On the floor of room #1was a white plastic cap, along with material that appeared to be leaves, dirt, hair, dust, and other debris. The floor integrity had multiple cracks and chips. This has the potential to allow fluids to get under the floor covering and onto the subfloor. This cannot be cleaned or sanitized without removing the floor covering. Upon removing the mattress cover and lifting the mattress away from the stretcher, a large brown, dry substance was found on the back of the mattress and the top of the stretcher. Stuck to the sink was a used sticky tab that was placed on the patient for electrocardiograms (ECG). Inside the infusion pump (the pump used to push medication through tubing into a patient's vein) drip chamber was a dried yellowish substance, dust, and debris. Staff #1 was asked if she believed this room was ready to receive a patient. Staff #1 stated, "No, it is not". Staff #1 confirmed the room was dirty and not ready to receive patients.

B. ED room 2.

Staff #1 and #6 were asked if this room was clean and ready to receive patients. Staff #1 and #6 stated, "Yes, this room is clean and ready to receive a patient". On the floor of room #2 was dirt, hair, dust, and other debris. The floor integrity had multiple cracks and chips. This has the potential to allow fluids to get under the floor covering and onto the subfloor. This cannot be cleaned or sanitized without removing the floor covering. After removing the mattress pad and lifting the mattress away from the stretcher, on the right railing and on the platform under the mattress pad were spots of a reddish-brown dried substance. Staff #1 and #6 were asked if they believed this room was ready to receive a patient. Staff #1 and #6 stated, "No, it is not". Staff #1 and #6 confirmed the room was dirty and not ready to receive patients.

C. ED room 6, the trauma room.

Staff #1 and #6 were asked if this room was clean and ready to receive patients. Staff #1 and #6 stated, "Yes, this room is clean and ready to receive a patient". On the floor of room #6 was dirt, hair, dust, and other debris. The floor integrity had multiple cracks and chips. This has the potential to allow fluids to get under the floor covering and onto the subfloor. This cannot be cleaned or sanitized without removing the floor covering. The IV (intravenous) pole (pole used to hang fluids and medication to be infused into patients) had a dried yellowish substance on the stand part of the pole. Staff #1 and #6 were asked if they believed this room was ready to receive a patient. Staff #1 and #6 stated, "No, it is not". Staff #1 and #6 confirmed the room was dirty and not ready to receive patients.

An interview was conducted on 8/17/2025 at 11:45 AM with the complainant (a Rusk State Hospital primary care tech (PCT) who was sent with another PCT to monitor the patient because of self-harm risk). Patient #2 was at risk of self-harm. The complainant stated that when they arrived at the hospital ED, patient #2 was brought into the ED room 1 by wheelchair. The complainant stated upon entering the room that she noticed that the "floor was dirty, and the bed had not been made". The complainant stated, "the room had white plastic caps from medical supplies on the floor, and that the floor just looked dirty". The complainant said that patient #2 "climbed up in the bed, but then a lady (the complainant did not know who this lady was) showed up and removed the bed from the room". The complainant stated that patient #2 "then sat in a chair that was in the room, and the same lady returned and removed the chair". The complainant asked the lady, "Where was the patient supposed to sit?". The lady replied that Patient #2 "could sit on the floor". Upon hearing this, Patient #2 "lay down on the dirty floor".

A medical record review of Patient #2 was performed on 8/19/2025 after 12:30 PM. In the medical record it states that Patient #2 came to the hospital ED on 7/24/2025 at 3:58 PM. Patient #2 had been previously discharged form this hospital on 7/23/2025 at 8:39 AM. The ED Triage note on 7/24/2023 states "Pt to ER from Rusk state w/ c/o foreign object in left flank wound. Per pt, she was recently admitted in this hospital for wound washout. Pt states that she stuffs 'things' in her wound. Pt reports that she stuffed 11 items in her wound last Saturday before her discharge from hospital yesterday. Foil, soda can tabs, paper clip type wire, etc are all stuffed in
wound per pt right after she got an xray last week." The ED physician attempted to remove the items in the ED but was unsuccessful. Because this hospital did not have a surgeon on call, Patient #2 was transferred to another facility for surgical services.


An interview was conducted with Staff #6 on 8/19/2025 after 12:30 PM. Staff #6 was asked which staff members are responsible for cleaning these rooms in the ED. Staff #6 stated, "The nurses are".

An interview was conducted with Staff #1 and #6 on 08/19/2025 after 12:30 PM. Staff #1 and #6 were asked how long the patient was without a place to sit in ED room #1. Staff #1 and 6 stated they were unsure of the exact time frame, but the bed was returned to the room. Staff #1 and #6 were asked di the patient lay down on the floor in ED room #1. Staff #1 and #6 were unable to confirm or deny that the patient lay on the floor of ED room #1.