HospitalInspections.org

Based on observation, interview and record review, the hospital failed to ensure a hospital-wide infection control program to prevent sources and transmission of infectious diseases and to adhere to nationally recognized infection prevention and control guidelines when:

1. Hand hygiene was not performed by X-ray Technician (XRAY) 1 when exited and entering operating rooms (OR) (Refer to A750 Finding 1)

2. Two ice dispensing machines had rough textured residue (anything that's left over when a substance has been removed,) on them. (Refer to A750 Finding 2)

3. Three washer/sterilizer machines (cleans, decontaminates, disinfects, and dries many common reusable medical instruments that are not heat-sensitive and can be submerged in water.) in the Sterile Processing Department Decontamination area had white, rough-textured (having a rough or uneven surface or consistency) residue (anything that's left over when a substance has been removed,) build-up on machine doors, door casings and machine surfaces (Refer to A750 Finding 3)

4. Shelving in the Sterile Processing Department Decontamination area was soiled with visible debris and with a plastic liner cracking and broken and were not maintained and sanitized. (Refer to A750 Finding 4)

5. The floors in operating room 3 and Sterile Processing Department Decontamination area were visibly stained with brown/black, yellow, and rust-colored stains trapped under the waxed surface and debris in floor corners and under equipment. (Refer to A750 Finding 5)

6. Two of six instrument tray labels on a sterile processing metal tray (two (2) labels per tray) were peeling, lifting, and cracking in the Prep and Pack area of Sterile Processing Department. (Refer to A750 Finding 6)

The cumulative effect of these systemic problems resulted in the hospital's inability to provide care in a safe setting.

Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary environment to avoid sources and transmission of infection when:

1. X-ray Technician (XRAY) 1 was observed to exit Operating Room (OR) 6 and did not perform hand hygiene (handwashing with soap and water or use of an alcohol-based hand sanitizer) after exiting OR 6 and before entering OR 7 in accordance with hospital policy and procedure.

2. Two of two ice dispensing machines; one in the OR and another in the Pre-Operative units had white, rough-textured residue built up on machine surfaces and on water catch trays in accordance with facility policy and procedure.

3. Three of three (Brand Name) washer/sterilizer machines (cleans, decontaminates, disinfects, and dries many common reusable medical instruments that are not heat-sensitive and can be submerged in water.) in the Sterile Processing Department (SPD- the process of cleaning, inspecting, disinfection and sterilization of medical devices used during a surgical procedure) Decontamination (Decon) area (a specific section or designated space where contaminated or soiled items are received, sorted, and prepared for the decontamination process), had white, rough-textured (having a rough or uneven surface or consistency) residue (anything that's left over when a substance has been removed,) build-up on machine doors, door casings and machine surfaces and staff did not sanitize and maintain the equipment in accordance with hospital P&Ps and manufacturer instructions for use (IFU).

4. Shelving in the SPD Decon area (a specific section or designated space where contaminated or soiled items are received, sorted, and prepared for the decontamination process) was soiled with visible debris and with a plastic liner cracking and broken and were not maintained and sanitized in accordance with hospital policy and procedures and Centers for Disease and control (CDC) guidance.

5. The floors in OR 3 and SPD Decon area were visibly stained with brown/black, yellow, and rust-colored stains trapped under the waxed surface and debris in floor corners and under equipment per hospital policy and procedure on how to clean, care for and maintain the of flooring in each department.

6. Two of six instrument tray labels on a sterile processing metal tray (two (2) labels per tray) were peeling, lifting, and cracking and did not comply with hospital policy and procedures inspection of instruments in the Prep and Pack area of the SPD.


These failures had the potential to allow for the spread of infection to all patients in the OR and the Medical-Surgical (MS) units.

Findings:

1. During a concurrent observation and interview on 7/9/24 at 1:59 p.m. in the OR unit with the OR Nurse Manager (ORNM) and the SPD Manager (MSPD) an X-ray Technician (XRAY) 1 was observed to exit OR 6, where an active surgery was in progress, and entered OR 7, which was being prepared to receive a surgical patient, without performing hand hygiene (handwashing with soap and water or use of an alcohol-based hand sanitizer) before and after patient contact. The MSPD and ORNM both acknowledged the observation in which XRAY 1 failed to wash hands as expected. MSPD stated at minimum they expect staff to alcohol [wash hands] per facility policy.

During an interview on 7/12/24 at 11:00 a.m., with the Director of Nursing (DON), the DON stated her expectations regarding the infection control concerns identified are that immediate action was taken by staff and leaders to correct the findings. DON stated hand hygiene is ongoing, with monitoring continuing but needs to be "amped up" with "secret shoppers [monitoring so staff does not see it being done]." DON stated the expectation and that all staff should be always performing hand hygiene.


During a review of policy titled, "Hand Hygiene Guidelines" last revised 11/2018, the policy indicated, ...Purpose: Proper hand washing and Standard/Universal Precautions has been identified as the most effective and simplest way to prevent infections, both inside and outside the hospital. The purpose of hand hygiene is to provide a mechanism whereby the risk of transmitting infection by contamination on the hands of healthcare workers is reduced or eliminated ...Policy: ...Standard Precautions [SP] are a set of infection control practices that healthcare personnel use to reduce transmission of microorganisms in the healthcare setting. SP protect both healthcare personnel and patients from contact with infectious agents. SP include: Hand Hygiene (handwashing with soap and water or use of an alcohol-based hand sanitizer) before and after patient contact and after contact with immediate patient care environment and Personal Protective Equipment (PPE) when exposure to blood, body fluids, excretions, ...or nonintact skin is anticipated ...Basic Hand Hygiene 1. Hands shall always be decontaminated, i.e., washed with soap and water and/or cleaned with an alcohol-based antiseptic agent (e.g. (brand name) gel) before and after each of the following and other similar activities: ...When moving from a contaminated body site to a clean body site during patient care ...After removing gloves ...Wearing gloves is not a substitute for hand hygiene ... Procedure: 1. If hands are not grossly soiled, apply a liberal amount of an approved alcohol-based hand sanitizer (e.g. (brand name) gel) to the palm of hand ...3. If hands are visibly soiled, wash hands with soap and water ..."

During a review of policy titled, "Infection Prevention & Control Plan" last revised 2/2024, the policy indicated, " ...Infection Prevention Goals ...Priority 4- Achieve and maintain hand hygiene compliance throughout the organization ...C. Objective: ...Staff to follow the "Five Moments of Hand Hygiene" established by the [global recognized organization]: 1) before patient contact, 2) before aseptic [free or freed from pathogenic (causing or capable of causing disease) microorganisms (an organism that can be seen only through a microscope)] task, 3) after body fluid exposure risk, 4) after patient contact, and 5) after contact with patient surroundings ...Infection Prevention and Control Focus Areas/Monitoring A. 1. Hand hygiene is recognized as the single most important means of preventing the spread of infection ..."

2. During a concurrent observation and interview on 7/9/24 at 2:50 p.m., with ORNM, MSPD and IP, in the OR and Pre-Operative units, two of two (Brand Name) ice dispensing machines had white textured residue on machine and on ice catch tray. IP stated the ice machines are cleaned daily by Environmental Services (EVS), the white residue looks like "hard water" spots. IP stated the potential for harm if the surface is not residue free is that bacteria can form and cause infection to patients.

During an interview on 7/12/24 at 11:00 a.m., with the Director of Nursing (DON), the DON stated her expectations regarding the infection control concerns identified are that immediate action was taken by staff and leaders to correct the findings. DON stated "Environment of Care (EOC)" rounds are not being done. DON stated the expectation is that floors would be clean, equipment is stain free and clean.

During a review of policy titled, "Infection Prevention & Control Plan" last revised 2/2024, the policy indicated, " ...Purpose: A. The Infection Prevention & Control Plan provides a description of the interdisciplinary and systematic approaches developed to reduce the transmission of communicable disease and infection ...Development of Goals ...B ...1. To identify and reduce the risks of acquiring and transmitting infectious agents among patients ...by pursuing sound infection control practices, ...as appropriate. 2. To limit unprotected exposure to pathogens (microorganisms that have the potential to cause infectious diseases). 3. To limit the transmission of infections associated with procedures ...4 ...with the use of medical equipment, devices, and supplies ...6. To maintain hand hygiene compliance ... I. Protecting Sterile Environment: ...1. Appropriate environmental decontamination, general cleanliness, disposal of biohazardous waste ...3. Standards of practice are followed for decontamination, sterilization, processing and storage of supplies and equipment. 4. Standards of aseptic technique and practice are followed that protect the sterile environment from contamination ..."

According to the "Food Code", dated 2017, " ...4.6 Cleaning of Equipment and Utensils ...4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (C) Nonfood-Contact Surfaces of Equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris ..."

3. During a concurrent observation and interview on 7/10/24 at 3:24 p.m., in the SPD, with MSPD and IP, three of three (Brand Name) washer/sterilizer machines had white, rough-textured (having a rough or uneven surface or consistency) residue (anything that's left over when a substance has been removed,) build-up on machine doors, door casings and machine surfaces in both the SPD Clean and SPD Decon areas. IP stated the machines are cleaned daily by EVS, the white residue looks like "hard water" spots, that were difficult to remove. IP stated the potential for harm if the surface is not residue free and smooth is bacteria can form and cross-contaminate (the physical movement or transfer of harmful bacteria from one person, object or place to another) equipment meant to be sterile with the potential to cause infection in patients.

During an interview on 7/12/24 at 11:00 a.m., with the Director of Nursing (DON), the DON stated the expectation regarding the infection control concerns identified are that immediate action was taken by staff and leaders to correct the findings. DON stated "Environment of Care (EOC)" rounds are not being done. DON stated the expectation is that floors would be clean, equipment is stain free and clean.

According to the "[Brand Name] Operator Manual" (undated) the Operating Manual indicated " ...6.6 Cleaning Washer/Disinfector Exterior ...The following cleaning procedure should be performed once per week: Clean washer/disinfector exterior using a general purpose cleaner (nonabrasive) for general stains, a stainless-steel stain remover for stubborn stains and a stainless-steel polish to keep equipment looking like new ...NOTE: Contact [Brand Name Company] for information on specific cleaning and descaling products recommended for use with this washer/disinfector ..."


During a review of policy titled, "Infection Prevention & Control Plan" last revised 2/2024, the policy indicated, " ...Purpose: A. The Infection Prevention & Control Plan provides a description of the interdisciplinary and systematic approaches developed to reduce the transmission of communicable disease and infection ...Development of Goals ...B ...1. To identify and reduce the risks of acquiring and transmitting infectious agents among patients ...by pursuing sound infection control practices, ...as appropriate. 2. To limit unprotected exposure to pathogens (microorganisms that have the potential to cause infectious diseases). 3. To limit the transmission of infections associated with procedures ...4 ...with the use of medical equipment, devices, and supplies ...6. To maintain hand hygiene compliance ... I. Protecting Sterile Environment: ...1. Appropriate environmental decontamination, general cleanliness, disposal of biohazardous waste ...3. Standards of practice are followed for decontamination, sterilization, processing and storage of supplies and equipment. 4. Standards of aseptic technique and practice are followed that protect the sterile environment from contamination ..."


According to the Centers for Disease Control (CDC), (undated) retrieved 7/17/24 from https://www.cdc.gov/infection-control/hcp/environmental-control/appendix-c-water.html, " Microorganisms have a tendency to associate with, and stick to surfaces ... These adherent organisms can initiate and develop biofilms (a thin layer of bacteria that adheres to the surface.)"


4. During a concurrent observation and interview on 7/10/24 at 2:56 p.m. in the SPD Decontamination (Decon) area with IP, shelving was soiled with visible debris present and a plastic shelf liner was cracked and broken. IP stated the shelving should be clean and debris [dust] free, with any liners on shelving free of dust and without cracks, breaks or missing pieces. IP stated the potential harm to patients is infection from cross-contamination.

During an interview on 7/12/24 at 11:00 a.m., with the Director of Nursing (DON), the DON stated the expectation regarding the infection control concerns identified are that immediate action was taken by staff and leaders to correct the findings. DON stated "Environment of Care (EOC)" rounds are not being done. DON expectation is that equipment is stain free and clean.


During a review of policy titled, "Cleaning and Disinfecting Reusable Patient Care Equipment" last revised 10/2023, the policy indicated, " ... Purpose: ...B... To ensure that proper cleaning and disinfection of reusable patient care equipment is performed after each patient use ... Definitions: A. Cleaning - The physical removal of foreign material, e.g. dust, oil, organic material such as blood, secretions, excretions, and microorganisms. Cleaning reduces or eliminates the reservoirs of potential pathogenic organisms. It is accomplished with water, detergents, and mechanical action. B. Disinfection - The inactivation of disease-producing organisms. Disinfection does not destroy high levels of bacterial spores. Disinfectants are used on inanimate objects. Disinfection usually involves chemicals, heat, or ultraviolet light. Levels of chemical disinfection vary with the type of product used ...Procedure: ...B. All equipment is to be cleaned according to the manufacturer's recommendations for normal cleaning/disinfecting ...D. Patient care equipment is cleaned, disinfected and/or reprocessed before reuse with another patient or before placed in storage ...H. Follow product recommendations for disinfectants (contact time, etc.) ...J. Allow equipment to air dry for the required time frame before using ...O. All horizontal and frequently touched surfaces will be cleaned daily and immediately when soiled ..."

During a review of policy titled, "Infection Prevention & Control Plan" last revised 2/2024, the policy indicated, " ...Purpose: A. The Infection Prevention & Control Plan provides a description of the interdisciplinary and systematic approaches developed to reduce the transmission of communicable disease and infection ...Development of Goals ...B ...1. To identify and reduce the risks of acquiring and transmitting infectious agents among patients ...by pursuing sound infection control practices, ...as appropriate. 2. To limit unprotected exposure to pathogens (microorganisms that have the potential to cause infectious diseases). 3. To limit the transmission of infections associated with procedures ...4 ...with the use of medical equipment, devices, and supplies ...6. To maintain hand hygiene compliance ... I. Protecting Sterile Environment: ...1. Appropriate environmental decontamination, general cleanliness, disposal of biohazardous waste ...3. Standards of practice are followed for decontamination, sterilization, processing and storage of supplies and equipment. 4. Standards of aseptic technique and practice are followed that protect the sterile environment from contamination ..."

5. During a concurrent observation and interview on 7/10/24 at 2:56 p.m., with ORNM, and IP in OR 3, the floors in OR 3 and SPD Decon area were visibly stained with brown/black, yellow, and rust-colored stains. IP stated the EVS staff cleans floor daily and as needed in between cases with a terminal clean at the end of each day. IP stated the floors are stained due to dirt being trapped under wax. IP stated the floors have not been stripped and waxed in some time due to a vacancy in the EVS department. During a concurrent observation and interview on 7/10/24 at 2:56 p.m., with ORNM, and IP in OR Three, the floors in OR 3 and SPD Decon area were visibly stained with brown/black, yellow, and rust-colored stains. IP stated the EVS staff cleans floor daily and as needed in between cases with a terminal clean at the end of each day. IP stated the floors are stained due to dirt being trapped under wax. IP stated the floors have not been stripped and waxed in some time due to a vacancy in the EVS department.

During an interview on 7/11/24 at 10:43 a.m., with EVS Coordinator (EVSC), EVSC stated the floors have not been stripped and waxed since April 2024.

During an interview on 7/12/24 at 9:53 a.m., with EVS 1, EVS 1 stated he is aware that hospital P&Ps require the EVS staff to clean the floors in between cases, as needed and when terminal clean is done (a thorough cleaning of a room after use) at the end of the day. EVS 1 stated he has observed the floor looks "dirty with stains maybe waxed in." EVS 1 stated he reports when the floor needs to be stripped and waxed to a supervisor and believes this is done once a week at night but is not sure because he works day shift.

During an interview on 7/12/24 at 11:00 a.m., with the Director of Nursing (DON), the DON stated the expectation regarding the infection control concerns identified are that immediate action was taken by staff and leaders to correct the findings. DON stated the floor needing to be stripped and waxed, and the ongoing process. DON stated "Environment of Care (EOC)" rounds are not being done yet. DON stated the expectation is that floors would be clean.

During a review of policy titled, "Infection Prevention & Control Plan" last revised 2/2024, the policy indicated, " ...Purpose: A. The Infection Prevention & Control Plan provides a description of the interdisciplinary and systematic approaches developed to reduce the transmission of communicable disease and infection ...Development of Goals ...B ...1. To identify and reduce the risks of acquiring and transmitting infectious agents among patients ...by pursuing sound infection control practices, ...as appropriate. 2. To limit unprotected exposure to pathogens (microorganisms that have the potential to cause infectious diseases). 3. To limit the transmission of infections associated with procedures ...4 ...with the use of medical equipment, devices, and supplies ...6. To maintain hand hygiene compliance ... I. Protecting Sterile Environment: ...1. Appropriate environmental decontamination, general cleanliness, disposal of biohazardous waste ...3. Standards of practice are followed for decontamination, sterilization, processing and storage of supplies and equipment. 4. Standards of aseptic technique and practice are followed that protect the sterile environment from contamination ..."

During a review of policy titled, "Daily and Terminal Cleaning Procedure of Operating Rooms" last revised 6/2020, the policy indicated, "Purpose: To establish the proper procedure for in-depth cleaning of the operating rooms, core, and associated areas ...Policy: Daily and terminal cleaning of operating rooms will be according to the following procedure. Procedure: ...2. Daily Cleaning Between Cases ...f. Wipe down all contaminated surfaces with disinfectant ...Use a "top-down" technique, saving floor for last ...i. Spray enzymatic cleaner on grossly soiled areas containing blood or fluids. Wet mop entire floor using a clean mop head and and disinfectant ... j. spot clean walls ...3. Daily Terminal Cleaning Procedure: a. Terminal cleaning to be performed at the conclusion of the day's procedures in each operating room, at the end of the day's surgery schedule. Each OR will be cleaned during each 24-hour period during the regular work week ...b. Operating rooms ...move all moveable equipment to the center of the room to properly clean the perimeter ...Wash walls ...from ceiling to floor. Was doors from top to bottom ...Wash all fixtures, equipment, furniture, and horizontal surfaces ...and including surgery table, autoclave exteriors, windows ledges, cabinets, IV poles, stools, tables, linen hampers, waste receptacles casters on equipment, ceiling tracks and sprinklers, clocks, tray equipment cords and arms ...Wet scrub floor. Clean baseboards ...c. Core and associated areas wash walls of scrub rooms ...Damp wipe all fixtures, equipment, furniture and horizontal surfaces ...Damp wipe the sub-sterile rooms, counter tops and carts ...Wash sink, faucets and exposed plumbing pipes ...4. Weekly Procedure: ...d. Flood floor area of entire OR: rooms, Core, sub-sterile rooms with disinfectant and machine scrub entire floor, then wet vacuum entire area ...e. ...Take items down from exposed shelves to clean shelves ..."

During a review of policy titled, "Housekeeping Cleaning Procedures" last revised 5/2021, the policy indicated, " ...Cleaning Non-Patient Care Areas Sterile Processing Department ...Daily ...Decontamination Area 1. Decontamination area work surfaces will be cleaned at the end of each shift by housekeeping with an approved disinfectant solution and as often as needed throughout the shift ...Sterile Preparation Area 1. Sterile assembly counters will be cleaned at the beginning of each shift by Sterile Processing with disinfectant solution and as often thereafter as necessary to ensure a lint-free surface. 2. Sterile supply shelving will be cleaned weekly by Sterile Processing Personnel with a disinfectant ...General Cleaning: 1. Wash all horizontal surfaces, including ...ledges, cabinets ...4. Damp wipe lift doors ...6. Damp wipe autoclave doors ...8. Wet mop floor. Clean baseboard ...Weekly 1. Wash walls from ceiling to floor ...2. Scrub and buff floors ...3. Clean all fixtures ...Floor Care ...Wet Mopping ...daily ...Machine Scrubbing Hard Surface Floors ...As needed or as specified in cleaning procedures for specific areas ...Machine Buffing Hard Surface Floors ...As needed ...Stripping and Waxing Floors ...As needed ..."


6. During a concurrent observation and interview on 7/11/24 at 9:10 a.m., in the SPD Prep and Pack Area (the preparation and packaging area refers to a designated space where decontaminated items are processed, inspected, packaged, and prepared for sterilization or storage.), with SPD Technician (SPDT) 2, MSPD and IP, two labels on a sterile processing metal tray were peeling, lifting, and cracking. SPDT 2 stated she "missed" identifying that the two labels were lifting, peeling, and cracking because the label(s) were still "scannable [bar code scan]." SPDT 2 stated during inspection of instruments during packing, checking the label included in the inspection process. SPDT 2 stated the process is to remove the old label using supplies like a scraper and adhesive removal as needed. SPDT 2 stated she then notifies her Lead or Manager to have new labels printed because SPDTs do not have access to print new label [from the computer system]. MSPD stated the maintenance of labels is an "ongoing" process, and the expectation is that staff are identifying labels that need to be changed out and processed immediately. SPDT 2 stated the potential harm in not removing these old labels is that particles of the label can land in the tray or onto instruments and contaminate the tray/instruments, breaking sterility.

During an interview on 7/12/24 at 11:00 a.m., with the Director of Nursing (DON), the DON stated her expectations regarding the infection control concerns identified are that immediate action was taken by staff and leaders to correct the findings. DON stated "Environment of Care (EOC)" rounds are not being done.

During a review of policy titled, "Cleaning and Disinfecting Reusable Patient Care Equipment" last revised 10/23, the policy indicated, " ... Purpose: ...B... To ensure that proper cleaning and disinfection of reusable patient care equipment is performed after each patient use ... Definitions: A. Cleaning - The physical removal of foreign material, e.g. dust, oil, organic material such as blood, secretions, excretions, and microorganisms. Cleaning reduces or eliminates the reservoirs of potential pathogenic organisms. It is accomplished with water, detergents, and mechanical action. B. Disinfection - The inactivation of disease-producing organisms. Disinfection does not destroy high levels of bacterial spores. Disinfectants are used on inanimate objects. Disinfection usually involves chemicals, heat, or ultraviolet light. Levels of chemical disinfection vary with the type of product used ...Procedure: ...B. All equipment is to be cleaned according to the manufacturer's recommendations for normal cleaning/disinfecting ...D. Patient care equipment is cleaned, disinfected and/or reprocessed before reuse with another patient or before placed in storage ...H. Follow product recommendations for disinfectants (contact time, etc.) ...J. Allow equipment to air dry for the required time frame before using ...O. All horizontal and frequently touched surfaces will be cleaned daily and immediately when soiled ..."

During a review of policy titled, "Infection Prevention & Control Plan" last revised 2/24, the policy indicated, " ...Purpose: A. The Infection Prevention & Control Plan provides a description of the interdisciplinary and systematic approaches developed to reduce the transmission of communicable disease and infection ...Development of Goals ...B ...1. To identify and reduce the risks of acquiring and transmitting infectious agents among patients ...by pursuing sound infection control practices, ...as appropriate. 2. To limit unprotected exposure to pathogens (microorganisms that have the potential to cause infectious diseases). 3. To limit the transmission of infections associated with procedures ...4 ...with the use of medical equipment, devices, and supplies ...6. To maintain hand hygiene compliance ... I. Protecting Sterile Environment: ...1. Appropriate environmental decontamination, general cleanliness, disposal of biohazardous waste ...3. Standards of practice are followed for decontamination, sterilization, processing and storage of supplies and equipment. 4. Standards of aseptic technique and practice are followed that protect the sterile environment from contamination ..."

During a review of policy titled, "Daily and Terminal Cleaning Procedure of Operating Rooms" last revised 6/2020, the policy indicated, "Purpose: To establish the proper procedure for in-depth cleaning of the operating rooms, core, and associated areas ...Policy: Daily and terminal cleaning of operating rooms will be according to the following procedure. Procedure: ...2. Daily Cleaning Between Cases ...f. Wipe down all contaminated surfaces with disinfectant ...Use a "top-down" technique, saving floor for last ...i. Spray enzymatic cleaner on grossly soiled areas containing blood or fluids. Wet mop entire floor using a clean mop head and and disinfectant ... j. spot clean walls ...3. Daily Terminal Cleaning Procedure: a. Terminal cleaning to be performed at the conclusion of the day's procedures in each operating room, at the end of the day's surgery schedule. Each OR will be cleaned during each 24-hour period during the regular work week ...b. Operating rooms ...move all moveable equipment to the center of the room to properly clean the perimeter ...Wash walls ...from ceiling to floor. Was doors from top to bottom ...Wash all fixtures, equipment, furniture, and horizontal surfaces ...and including surgery table, autoclave exteriors, windows ledges, cabinets, IV poles, stools, tables, linen hampers, waste receptacles casters on equipment, ceiling tracks and sprinklers, clocks, tray equipment cords and arms ...Wet scrub floor. Clean baseboards ...c. Core and associated areas wash walls of scrub rooms ...Damp wipe all fixtures, equipment, furniture and horizontal surfaces ...Damp wipe the sub-sterile rooms, counter tops and carts ...Wash sink, faucets and exposed plumbing pipes ...4. Weekly Procedure: ...d. Flood floor area of entire OR: rooms, Core, sub-sterile rooms with disinfectant and machine scrub entire floor, then wet vacuum entire area ...e. ...Take items down from exposed shelves to clean shelves ..."

During a review of policy titled, "Housekeeping Cleaning Procedures" last revised 5/2021, the policy indicated, " ...Cleaning Non-Patient Care Areas Sterile Processing Department ...Daily ...Decontamination Area 1. Decontamination area work surfaces will be cleaned at the end of each shift by housekeeping with an approved disinfectant solution and as often as needed throughout the shift ...Sterile Preparation Area 1. Sterile assembly counters will be cleaned at the beginning of each shift by Sterile Processing with disinfectant solution and as often thereafter as necessary to ensure a lint-free surface. 2. Sterile supply shelving will be cleaned weekly by Sterile Processing Personnel with a disinfectant ...General Cleaning: 1. Wash all horizontal surfaces, including ...ledges, cabinets ...4. Damp wipe lift doors ...6. Damp wipe autoclave doors ...8. Wet mop floor. Clean baseboard ...Weekly 1. Wash walls from ceiling to floor ...2. Scrub and buff floors ...3. Clean all fixtures ...Floor Care ...Wet Mopping ...daily ...Machine Scrubbing Hard Surface Floors ...As needed or as specified in cleaning procedures for specific areas ...Machine Buffing Hard Surface Floors ...As needed ...Stripping and Waxing Floors ...As needed ..."