HospitalInspections.org

Based on observation and interview, the facility failed to provide and maintain a sanitary environment resulting in the potential for the spread of infectious disease to all patients served by the facility. Findings include:

On 09/14/2015 beginning at 1030 during the tour of the four medical surgical units the following was found:
1.) 3 East- at 1040 the medication room upper and lower cupboards were splattered with a dry brown substance inside and out. The door ledges of the cupboards had thick layers of a dried brown substance, staff E was able to use a wet paper towel to remove some of the substance. Staff E was asked if the locked medication room was on a scheduled cleaning cycle. Staff E replied, "I am not sure, but I will find out." Further observation of the medication room revealed that the "Pixis" (automated medication access computer and dispenser) had a thick accumulation of gray dust, and black speckled debris in the bottom of the medication storage tower. Staff E was asked who was responsible for keeping the medication storage tower cleaned. Staff E replied, "the pharmacy is I believe, but I will find out." Further observation of the medication drawer storage reveled that when the plastic liner was lifted there was an accumulation of dust, debris, and a dried brown substance. Staff E stated, "the pharmacy technicians fill those cubes, I do not know if they are supposed to clean them first." At 1050 the tour continued, the patient nourishment room was found to have cupboards uppers and lowers that had splatters of a dried brown substance inside and out, the drawers had accumulations of dust, debris, and crumbs. The inside of the microwave had dried splatters covering the inside. Staff E was asked who was responsible for cleaning the nourishment room, and if it was on a scheduled cleaning cycle. Staff E responded, "I do not know but I will find out." A continued tour revealed a second medication room with a second "Pixis" to help with the demand for medications. The medication tower was found to have a thick layer of gray dust, and debris in the bottom that was easily swiped with a finger of this surveyor. Staff E stated, "we are checking our policies to find out who is responsible for the medication rooms, pixis, and the nourishment rooms."
2.) at 1105 the tour continued on 3 West, the medication room upper and lower cupboards were splattered with a dry brown substance inside and out. The door ledges of the cupboards had thick layers of a dried brown substance, when asked about the cleaning schedule Staff E replied, "I have not found out yet." Further observation of the medication room revealed that the "Pixis" (automated medication access computer and dispenser) had a thick accumulation of gray dust, and black speckled debris in the bottom of the medication storage tower and the medication drawer storage revealed that when the plastic liner was lifted there was an accumulation of dust, debris, and a dried brown substance. Staff E stated, "yes I see that the medication storage areas need to be cleaned." On 9/14/15 at 1110 the tour continued, the patient nourishment room was found to have cupboards uppers and lowers that had splatters of a dry brown substance inside and out, the drawers had accumulations of dust, debris, and crumbs. The inside of the microwave had dried splatters covering the inside. The second medication room "Pixis" medication tower was also found to have a thick layer of gray dust, and debris in the bottom. This was confirmed by staff E.
3.) The tour of 4 East, and 4 West was begun at 1300 with staff O as guide. The medication rooms on 4 East and 4 West with the "Pixis" were also found to have cupboards splattered with dried brown substances, door ledges that had thick layers of dried brown substances that could be wiped away, and visible dust and debris in the bottom of the medication storage towers. The patient nourishment rooms were found to have cupboards uppers and lowers that had splatters of a dry brown substance inside and out. The drawers had accumulations of dust, debris, and crumbs. The microwave had dried splatters covering the inside. Staff O did not respond to questions regarding these observations.

On 09/14/2015 at 1120 two environmental service supervisors met with this surveyor to discuss medication room and nourishment room cleaning. Staff F and G stated, "we have had a gap in our communication and our policies, no one is assigned the over all cleaning of the medication rooms or nourishment rooms."

On 09/14/2015 at 1200 staff H, pharmacist was asked who was responsible for cleaning the medication storage towers and drawers. He stated, "our policy fails to address who is responsible for keeping them cleaned."


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During an observation of a surgical procedure in the operating room on 9/15/15 at 1025, Surgical Tech "P" was observed placing her gloved hand on top of a waste receptacle after the surgical case was completed and pushing the full garbage down, half way into the waste receptacle. Surgical Tech "P" was wearing a short sleeved scrub top, leaving her bare arms exposed to the garbage in the waste receptacle, which contained contaminated items from the surgical procedure, including the gloves and gowns worn by the staff who performed the procedure.