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Based on observation, interview and record review, the facility failed to sanitize 5 ( 310, 312, 315, 318 and 325) of 5 rooms observed in Same Day Surgery.

The Findings Include:


A. During a tour of the Same Day Surgery Unit on August 04, 2016 at 10:14 AM, Room 315 was toured and visual inspection demonstrated a very neatly made-up bed, gown and supplies set up in the center of the bed. At this time, the Same Day Surgery Manager was asked if this room is about to receive a patient; she stated, "Yes, this room is ready to receive a patient." During a tour of the room and examination of the patient care area, a bloody gauze and paper debris were observed in the trash can for this room.

The Same Day Surgery Manger confirmed that her staff has 21 patient care rooms for which they are responsible for cleaning. She also stated that environmental services do not clean the Same Day Surgery rooms during the day.

During the tour of the Same Day Surgery Area, the Same Day Surgery Manager confirmed that of the 21 rooms on this unit, Rooms 310, 312, 315, 318 and 325 are rooms that were "cleaned" by staff for next patient occupancy and each room was observed to have trash retained in the room, on August 04, 2016 at 10:14 AM.

B.) During a tour of the Emergency Department (ED), Employee B was observed at 11:40 AM, cleaning an ED Room. He was interviewed, stating, "I have been here nine years. Housekeeping cleans Isolation Rooms. Policy requires me to wipe down all of the equipment". He is observed wiping down all of the blood pressure equipment, bedside tables, IV poles, wires and counter tops.

C.) During an interview with (Employee A) in the Emergency Department (ED) Assessment Area on August 04, 2016 at 2:02 PM, a male arrived at 2:03PM, presenting with a foot problem. He had cellulitis once before, the female accompanying the patient stated. She repeated, "He had cellulitis before." The blood pressure cuff was observed to be applied directly to the patient's skin by Employee A at 2:04 PM. Employee A stated, "Inflammation to Left foot" to the registration desk. The female with the patient then stated, "It is cellulitis". Employee A stated, "I know you said that, but we cannot make that diagnosis out here." A small handwritten paper with vital signs documented was handed to registration. The patient's blood pressure was 144/71, with heart rate result and pulse ox at 100%. The blood pressure cuff was removed from the patient and draped over blood pressure machine at 2:07 PM. (The blood pressure cuff was not wiped with any cleaning solution.) The male patient was dismissed from ED Assessment Chair and was then called back to ED Area.

On August 04, 2016 at 2:19 PM, a second male arrived to Triage Assessment Area, asking for a letter from a doctor, stating, "From my medical records to get my social security card". Employee A was observed taking the blood pressure cuff from the top of the machine and applied the cuff to this male patient without any cleansing with purple super Sani-cloth wipes.



An interview was conducted on August 04, 2016 at 3:45 PM with the Director of Infection Prevention and Director of Environmental Services. They stated that it is a standard for cleaning all rooms, "The same day surgery rooms are cleaned every night, including cleaning the floors and walls and removing the trash. During the day, the staff are supposed to empty the trash cans and this occurs in all areas. Trash is the first thing that should be taken out of the room. Bloody gauze should not be seen in a room that was cleaned for a patient; if the room had been cleaned, the trash should have been emptied. If we are using reusable blood pressure cuffs, then they should all be used with the purple top cleanser between all patients."



A review of the facility provided policy, "Cleaning and Disinfection General Rules and Definitions" was conducted and documented under Section V. PROCEDURE: a. All patient rooms are cleaned by Environmental Services procedure daily and upon patient discharge, using the approved hospital disinfectant. All non-critical patient care items shall be cleaned, and disinfected between EACH patient use or when visibly soiled. ii. All non-critical patient care equipment such as commode chairs, BLOOD PRESSURE CUFFS or any item in contact with intact skin will be disinfected with the approved intermediate level disinfectant after EACH patient use.