HospitalInspections.org

Based on observation, interview and document review, the facility failed to ensure the facility followed the directions for cleaning/disinfecting chairs in the the Emergency Department waiting/lobby area, wore masks properly, preformed hand hygiene after removing gloves, and maintained the facility in a manner that would enable the staff to clean and disinfect the floors and walls.

The findings include:

On December 14, 2020 at approximately 11:30 A.M., the Emergency Department (ED) was inspected starting in the lobby/waiting area with Staff Member #1, Regulatory Compliance, and Staff Member #3, Director of the ED. There were approximately eight (8) people in the ED waiting area, one in the initial triage area, and two (2) in the data collection area. (The data collection area is were some initial labs, x-rays and information is gathered.)

A staff member was observed wiping down the chairs in the waiting area and turning chairs to face the wall. The chairs were not six feet apart. The product being used to clean and disinfect the chairs was Sani-Wipes from a purple top container. The disinfect wet time noted on the wipes container was two (2) minutes. Instructions on the container document the item being disinfected must remain wet for two (2) minutes and then allowed to air dry. Staff Member #1 was observed speaking to the person cleaning and disinfected the chairs about the wet time required. Staff Member #1 stated, "We will have to look for a product that works faster. Patients are not going to stand and wait until the chairs are dry. We might be able to clean chairs and turn the unused chairs around to be used while the used ones are drying."


After the lobby, the main ED was observed. Nursing and Medical Staff were observed wearing their mask but four (4) direct care staff were observed repeatedly touching the front of their mask. Two (2) were observed hanging their N 95 mask at the waist and wrapped around their upper arm.

In the main ED, one physician was observed removing their gloves after performing direct patient care and not performing hand hygiene. Staff Member #1 confirmed the observed lack of hand hygiene.

Policy/Procedure titled IP&C Hand and Fingernail Hygiene #204 Revised 6/8/2020 reads as follows:
Required Action Steps: #4 When to wash with alcohol-based hand sanitizer. Supplemental Guidance: #4...Before donning and after doffing gloves...

A tour of the main ED noted the following:
The floor in the main ED had cracks, breaks and holes throughout the entire hallway, patient care rooms and at doorways leading to and from the main ED. In Trauma Bay room #1, there was an area approximately fourteen (14) by nine (9) inches where there was no covering over the cement. The floor in Critical room #2 had cracks and breaks in the floor.

Cracks and breaks in the floor leave areas where moisture, blood and other body fluids can permeate making them impossible to clean and disinfect after a blood or body fluid spill.

Along the hallways, there were handrails made from a plastic like material. The end caps of the handrails in several areas were missing leaving exposed sharp edges. Staff Member #3 stated, "We put in work orders, they get repaired and then they are off again."

Many of the walls throughout the ED were covered in FRP (Fiberglass-reinforced polymer). The trim for the FRP was cracked and broken leaving sharp splintery edges that could easily be broken off and making the FRP difficult to keep clean. In places were there was no FRP, there was painted drywall. The drywall had torn facer and baker paper, breaks and holes leaving the exposed chalk like material exposed.

When drywall is exposed to water (or moisture) for too long it can get damaged. It may lose its structural integrity, becoming soft and weak. The broken areas of the drywall cannot be cleaned and disinfected if exposed to blood and other body fluids.

There were visible splatters of what appeared to be blood on the disposable curtains in Critical room #2. The date on the curtain was 4/9/2020. Staff Member #3 explained, "I believe that was the last time the curtain was changed. I think they have to be changed every six (6) months. Looks like they should have been changed, we will get right on that."

Policy/Procedure titled ESD and IP&C Cleaning of Cubicle Curtains revised 2/20/2020. Reads as follows:
Purpose: Environmental cleaning is a team effort. Curtains (reusable and disposable) will be replaced anytime they become visibly soiled or at discharge in an identified isolation room. All cubicle curtains (reusable and disposable) will be changed every 180 days.

The area behind Triage had three (3) to four (4) ceiling tiles that appeared to be in various stages of drying from previously being wet. Staff Member #3 stated, "We use this area for Triage overflow. Last week, we used it for an overflow of behavioral health patients. We deal with leaks in here every time it rains."

Upon leaving the main ED, the survey and hospital team walked down the hallway separating the radiology department and ED. (This hallway is used to move patients from the ED to radiology.) The floor hand numerous cracks and breaks.