HospitalInspections.org

Based on document review, observation, and interview, the facility failed to remove regular and biohazardous trash from cleaned patient rooms for 2 of 3 unoccupied rooms in the special care unit (SCU).

Findings include:

1. Facility policy titled "CLEANING PATIENT ROOM AFTER DISCHARGE/TRANSFER" last reviewed/revised 12/12/12 states under procedure: "Empty all waste containers. The waste containers will be wiped out with a hospital approved germicidal solution and bag liners replaced......"

2. Facility policy titled "HANDLING AND DISPOSAL OF MEDICAL WASTE" last reviewed/revised 5/21/12 states under policy on page 1: "Contaminated/Bio Hazardous Medical Waste shall be collected in Red Trash Bags marked Infectious Waste. Daily,the Red Bags are to be collected in a mobile collection cart, with a lid and transported to the incinerator building......."

3. Review of housekeeping Performance Improvement documents indicated the following:
(A) The target goal for unoccupied room cleanliness on the SCU is 95%.
(B) The second quarter of fiscal year 2013 the rate of SCU discharge rooms cleanliness was 93.1%.
(C) The third quarter fiscal year 2013 the rate of SCU discharge rooms cleanliness was 94.1%.

4. During tour of the SCU beginning at 11:50 a.m. on 07/25/13 and accompanied by RN #1, the following was observed:
(A) Room #2, unoccupied and clean, had trash in the trash can including, but not limited to, electrodes and gloves.
(B) Room #4, unoccupied and clean, had a Foley catheter and tubing in the biohazardous trash can.

5. RN #1 verified the above observations during tour and indicated the following in interview beginning at 12:10 p.m. on 7/25/13:
(A) The last patient in room #2 was discharged on 7/18/13.
(B) The last patient in room #4 was discharged on 7/24/13 and the patient did have a Foley catheter that was discontinued on 7/24/13.

6. Staff member #A1 indicated the following in interview at 12:15 p.m. on 7/25/13:
(A) He/she selects ten (10) rooms a month for a walk through and the next walk through is due on 7/26/13.
(B) All four (4) of the SCU rooms are checked each month.
(C) Biohazardous waste containers are not generally kept in a patient room. If they are, they would be emptied by housekeeping after the patient is discharged.