HospitalInspections.org

The Condition of Participation for Governing Body has not been met.

Based on review of documentation, meeting minutes, observation, and interviews with staff, the Governing Body failed to ensure that physical environment and infection control findings that had been identified in the hospital's sterile Central Processing Department (CPD) were remedied to avoid sources and transmission of infectious and communicable diseases and ensure that infection control standards of practice were maintained.



Please cross reference A700, A701, A747, A749 and A756.



The areas of identified non-compliance are as follows:

a. Observations in the CPD sterile area on 9/17/19 and 9/19/19 identified multiple separated and/or broken floor tiles, build-up of dirt on tiles throughout the CPD and multiple physical plant deficiencies that contributed to unsanitary conditions and the prevention of sterility in the CPD.
b. Daily mopping of the CPD floor during packaging and sterilization of surgical instrumentation.
c. Rust and/or lime build- up inside three of three observed steam sterilizers.
d. Three month delay in yearly contracted company servicing of two steam sterilizers and lack of scheduled yearly servicing of two steam sterilizers.
e. Infection Control meeting minutes did not reflect CPD environmental issues as an identified IC issue.

Interview with the CEO (Chief Executive Officer), Governing Body Member, identified that although he was aware of the need to replace the CPD flooring, he was not aware of the infection control issues and/or physical plant issues within the CPD.

The Patient Safety and Quality Assessment and Performance Improvement Plan identified that the Board of Trustees (Governing Body) is ultimately accountable for, in part, the systems and process to support care and to approve resources to support improvement plans and set improvement priorities.

The Condition of Participation for Physical Environment has not been met.

Based on observations during tour of the Central Processing Department (CPD) and the surgical suites, interviews, policy and documentation review, and review of manufacturers recommendations, the hospital failed to ensure that the environment was maintained in a clean and sanitary condition, failed to ensure proper maintenance of equipment and/or physical environment, failed to ensure that sterilizer cleaning was maintained and failed to ensure proper life safety signage was in place.

Please see A701

Based on observations during tour of the Central Processing Department (CPD), the surgical suites and endoscopy suite, interviews, policy and documentation review, review of manufacturers recommendations and review of national standards, the hospital failed to ensure that the environment was maintained in a clean and sanitary condition, failed to ensure proper maintenance of equipment and physical environment, failed to ensure that sterilizer cleaning was maintained, failed to ensure proper life safety signage was in place and failed to ensure that scope storage closets were properly vented. The findings include:



a. A tour of the CPD was performed with the Administrator of Surgical Services on 9/17/19. Observations on 9/17/19 beginning at 11:24 AM identified multiple separated and/or broken areas of flooring tile in the sterile side of the CPD rendering the floor unable to be properly sanitized, linen on the floor of the sterile side of the CPD near a decommissioned sterilizer (practice since 2017 to maintain air pressure) and flooring throughout the CPD sterile area was observed with a build-up of dirt and debris to include the flooring next to the instrument wrapping area.

In addition, on 09/19/19 between 10:09 AM and 10:55 AM the surveyor, accompanied by a representative of the Engineering Department, observed the following:

i. the area around the "old sterilizer" within the "clean side" of the CPD had exposed electrical conductors and wiring, open unsecured access panels that surround the sterilizers, aluminum tape covering sheet metals joints, and duct tape in use to secure panels and wiring, negating the assemblies' ability to maintain the required air pressures/balancing and maintenance of a sanitary condition within the space.

ii. the exhaust ductwork over the instrument area was lacking registers, exposing the interior ductwork.

iii. multiple fluorescent lighting fixtures within the CPD were missing protective covers, negating the ability to maintain a sanitary condition.

iv. multiple work stations and carts within the CPD had peeling and flaking paint on the lower shelves, negating the ability to maintain a sanitary condition.

v. multiple high horizontal surfaces (e.g; door closer arms, door casing frames, shelving, clocks, etc.) within the CPD had a significant accumulation of dirt and debris, negating the ability to maintain a sanitary condition.

vi. multiple floor surfaces within the CPD clean side had a significant accumulation of dirt and debris, negating the ability to maintain a sanitary condition.

vii. multiple plug strips and extension cords in use within the CPD near the assembly area.

viii. numerous ceiling tiles within the "clean side" of the CPD were either ajar or missing, negating the assemblies' ability to maintain the required air pressures/balancing within the space.

ix. the CPD clean side lacked adequate signage to indicate the location of the emergency egress routes.

Review of environmental/infection control rounds on 9/18/19 at 9:34 AM identified that the CPD floor has had cleanliness and disrepair issues documented prior to November 2017 and continued through to November 2018. The environmental/infection control rounds did not identify cleanliness issues during the rounds dated 6/4/19. The flooring disrepair continued to be a current issue (9/17/19) with repeated documentation of postponement of the flooring repair.

Interview with the Manager of Environmental Services on 9/17/19 at 11:46 AM indicated that the CPD floor was mopped daily after lunch (during sterile reprocessing).

Interview with the Supervisor of CPD on 9/17/19 at 1:30 PM identified that the repossessing and packaging of instruments is performed daily until 11:00 PM.

Interview with the Infection Preventionist (IP) on 9/17/19 at 2:51 PM noted that she was under the impression the CPD floor was mopped on the evening shift when things slowed down (during sterile reprocessing). In addition, the IP indicated environmental and safety rounding was last performed by these departments in the CPD on 1/30/18 and 8/28/18 respectively.

Interview with the Director of Facilities on 9/18/19 at 1:08 PM indicated that broken floor tiles would be replaced with the submission of a work order or when notified by the IP following rounding.

Interview with the Housekeeping Manager on 9/19/19 at 2:21 PM identified that rounding was conducted monthly in the CPD to ensure cleanliness yet the documentation of the rounding could not be provided.

The hospital's infection control policy for the CPD identified to see environmental services for cleaning in CPD.

The hospital's environmental cleaning policy for CPD identified that Environmental Services and Engineering Departments are responsible for completion and documentation of their designated environmental cleaning. The policy did not identify the time that the cleaning would take place.

The current (2019) central processing supervisor job description included an essential function to assure that the standards of operation of the department are in compliance with the standards set by regulatory agencies.


The hospital submitted an immediate action plan dated 9/17/19 to include in part, immediate broken floor tile replacement and cleaning, revision of the CPD cleaning schedule to identify cleaning to be performed after hours when no sterile processing is occurring, sterilizer cleaning, decommissioned sterilizer enclosure placement and ceiling, flooring and lighting replacement within 45 days. The hospital policy for clinical requirements, infection control identified that the entire CPD will be cleaned by Environmental Services personnel daily following strict guidelines.




b. A tour of the surgical suites in the main OR (operating room) was conducted on 9/17/19 and/or 9/19/19. Observation of OR #2 on 9/17/19 at 9:30 AM identified two areas of sticky tape remnants on the vinyl padding of the OR arm rest.

Observation of the endoscopy suite on 9/17/19 indicated two areas of sticky tape remnants on the vinyl covering of the procedure table. The sticky tape remnants rendered the equipment unable to be properly sanitized.

Interview with the Administrator of Surgical Services on 9/17/19 at 9:30 AM indicated that OR equipment was sanitized by using a lint-free cloth and Virex solution.

On 09/19/19 at 09:20 AM the surveyor, accompanied by a representative of the Engineering Department, observed during a tour of Operating Room #5 that there was a significant accumulation of dust and dirt on numerous horizontal surfaces throughout the entire room. Surfaces included "high reach" areas of door closer arms, door frame casings, cabinets and clocks. At the time of the survey, Operating Room #5 was functioning as an operating room with no indication of any current or past construction being conducted within this space to account for the accumulation of dust.

In addition, observed during a tour of Operating Room #5 that there was wall damage, peeling paint, and bare drywall surfaces, negating the ability to maintain a sanitary condition. NOTE: at the time of the survey, Operating Room #5 was functioning as an operating room with no indication of any current or past construction being conducted within this space.

The hospital's environmental sanitation and operating room policy identified that prior to opening supplies for the first scheduled procedures of the day, all horizontal surfaces within the OR must be damp wiped. The policy further noted that end of day cleaning by environmental services included, in part, a thorough cleaning of furniture and equipment.



c. A tour of the OR and/or CPD was conducted on 9/17/19. Observations on 9/17/19 at 9:43 AM identified two steam sterilizers in the inner core of the OR of which one was deemed out of service. The observation further noted that the functional steam sterilizer had a build- up of rust on the door lip, flooring and shelving. Both sterilizers lacked signage for when the sterilizers were last cleaned.

Observations on 9/17/19 at 11:30 AM noted that the CPD department had two steam sterilizers. The insides of both sterilizer indicated a build- up of lime especially on the back wall. The sticker on the outside of each machine was faded and the readable portion of the date identified that cleaning was due 6/2019. Interview with the Director of Surgical Services on 7/17/19 at 9:43 AM noted that she did not consider having the two steam sterilizers cleaned by the company.

Interview with the CPD Supervisor on 9/17/19 at 1:30 PM indicated that he hadn't had the chance to schedule the company to clean/inspect the steam sterilizers. In addition, interview with the CPD Supervisor on 9/17/19 at 1:30 PM indicated that the sterilizer drains are rinsed daily although documentation of staff cleaning of sterilizers was lacking.

The hospital did not have a policy that identified how often the contracted company should clean/inspect the facility sterilizers, the sterilizer's manufacturer recommendations identified to reference the standards of AAMI (Association for the Advancement of Medical Instrumentation). The AAMI standard for preventive maintenance/general considerations identified that the manufacturer should provide written instructions for use for preventive maintenance of the equipment and the frequency of maintenance depends on how often the equipment is used.



d. A tour of the endoscopy suite was conducted with the Lead Technician on 9/17/19. Observations at 10:22 AM identified two scope storage closets in the department. The observations further identified that the closets were not vented. Interview with the Facilities Director on 9/17/19 at 10:43 AM indicated that the closets did not have to be vented because the pressure inside and outside of the closets were the same. The hospital scope cleaning policy identified, in part, that the storage cabinet must be clean, dry and well ventilated



e. Tour of the LDRP suite with Director #3 and Manager #3 on 9/17/19 at 9:45 AM identified rusted, pitted castors on the IV pole in operating room #2. The rust prohibited the IV pole from being properly cleaned. Director #3 identified the surfaces and equipment in the operating rooms are cleaned after each case using hospital approved disinfectant.

The hosital's environmental sanitation and OR cleaning policy identified that end of day cleaning by environmental services included, in part, a thorough cleaning of furniture and equipment.

Based on observations during tour of the surgical department to include the Central Processing Department (CPD), surgical suite and the endoscopy suite, interviews, policy and documentation review, and review of manufacturers recommendations and review of national standards the hospital failed to ensure that the environment was maintained in a clean and sanitary condition to avoid sources and transmission of infectious and communicable diseases when unsanitary conditions were identified in the CPD, failed to ensure that sterilizer cleaning was maintained and/or that sterilizer cycles/loads were properly monitored, failed to ensure that IV (intravenous) fluids had not expired, and failed to ensure that staff adhered to hospital infection control policies/practices including proper hair covering and attire and failed to ensure that scope storage closets were properly vented, failed to ensure that IV (intravenous) fluids and/or medications had not expired, failed to ensure that medication/nourishment refrigerators, freezers and warming cabinet temperatures were consistently monitored, failed to maintain a sanitary environment, failed to ensure appropriate surgical attire was donned in the labor and delivery surgical suite, and failed to ensure that environmental issues identified by the Infection Preventionist (IP) were also identified as Infection Control (IC) issues and not solely environmental repair issues.



Please see A749 and 756

Based on observations, interviews, policy and documentation review, review of manufacturers recommendations and review of national standards the hospital failed to ensure a system was maintained for a clean and sanitary environment in the Central Processing Department (CPD) to prevent potential sources of infectious and communicable disease transmission, failed to control policies/practices, failed to ensure proper ventilation of scope storage closets, failed to ensure IV (intravenous) fluids and medications had not expired, failed to ensure that medication/nourishment refrigerators, freezers and warming cabinet temperatures were consistently monitored, failed to ensure appropriate surgical attire was donned in the labor and delivery surgical suite, and failed to ensure that environmental issues identified by the Infection Preventionist (IP) were also identified as Infection Control (IC) issues and not solely environmental repair issues. The findings include:


a. A tour of the CPD was performed with the Administrator of Surgical Services on 9/17/19. Observations on 9/17/19 beginning at 11:24 AM identified multiple separated and/or broken areas of flooring tile in the sterile side of the CPD rendering the floor unable to be properly sanitized, linen on the floor of the sterile side of the CPD near a decommissioned sterilizer (practice since 2017 to maintain air pressure) and flooring throughout the CPD sterile area was observed with a build-up of dirt and debris to include the flooring next to the instrument wrapping area.

In addition, on 09/19/19 between 10:09 AM and 10:55 AM the surveyor, accompanied by a representative of the Engineering Department, observed the following:

i: the area around the "old sterilizer" within the "clean side" of the CPD had exposed electrical conductors and wiring, open unsecured access panels that surround the sterilizers, aluminum tape covering sheet metals joints, and duct tape in use to secure panels and wiring, negating the assemblies' ability to maintain the required air pressures/balancing and maintenance of a sanitary condition within the space.

ii: the exhaust ductwork over the instrument was area was lacking registers, exposing the interior ductwork.

iii: multiple fluorescent lighting fixtures within the CPD were missing protective covers, negating the ability to maintain a sanitary condition.

iv: multiple work stations and carts within the CPD had peeling and flaking paint on the lower shelves, negating the ability to maintain a sanitary condition.

v: multiple high horizontal surfaces (e.g.; door closer arms, door casing frames, shelving, clocks, etc.) within the CPD had a significant accumulation of dirt and debris, negating the ability to maintain a sanitary condition.

vi: multiple floor surfaces within the CPD clean side had a significant accumulation of dirt and debris, negating the ability to maintain a sanitary condition.

vii: multiple plug strips and extension cords in use within the CPD near the assembly area.

viii: numerous ceiling tiles within the "clean side" of the CPD were either ajar or missing, negating the assemblies' ability to maintain the required air pressures/balancing within the space.


Review of environmental/infection control rounds on 9/18/19 at 9:34 AM identified that the CPD floor has had cleanliness and disrepair issues documented prior to November 2017 and continued through to November 2018. The environmental/infection control rounds did not identify cleanliness issues during the rounds dated 6/4/19. The flooring disrepair continued to be a current issue (9/17/19) with repeated documentation of postponement of the flooring repair.

Interview with the Manager of Environmental Services on 9/17/19 at 11:46 AM indicated that the CPD floor was mopped daily after lunch (during sterile reprocessing).

Interview with the Supervisor of CPD on 9/17/19 at 1:30 PM identified that the repossessing and packaging of instruments is performed daily until 11:00 PM.

Interview with the Infection Preventionist (IP) on 9/17/19 at 2:51 PM noted that she was under the impression the CPD floor was mopped on the evening shift when things slowed down (during sterile reprocessing). In addition, the IP indicated environmental and safety rounding was last performed by these departments in the CPD on 1/30/18 and 8/28/18 respectively.

Interview with the Director of Facilities on 9/18/19 at 1:08 PM indicated that broken floor tiles would be replaced with the submission of a work order or when notified by the IP following rounding.

Interview with the Housekeeping Manager on 9/19/19 at 2:21 PM identified that rounding was conducted monthly in the CPD to ensure cleanliness yet the documentation of the rounding could not be provided.

The hospital's infection control policy for the CPD identified to see environmental services for cleaning in CPD.

The hospital's environmental cleaning policy for CPD identified that Environmental Services and Engineering Departments are responsible for completion and documentation of their designated environmental cleaning. The policy did not identify the time that the cleaning would take place.

The hospital submitted an immediate action plan dated 9/17/19 to include in part, immediate broken floor tile replacement and cleaning, revision of the CPD cleaning schedule to identify cleaning to be performed after hours when no sterile processing is occurring, sterilizer cleaning, decommissioned sterilizer enclosure placement and ceiling, flooring and lighting replacement within 45 days. The hospital policy for clinical requirements, infection control identified that the entire CSD will be cleaned by Environmental Services personnel daily following strict guidelines.




b. A tour of the surgical suites in the main OR (operating room) was conducted on 9/17/19 and 9/19/19.

Observation of OR #5 on 9/17/19 at 9:30 AM identified the Certified Registered Nurse Anesthetist (CRNA) dressed in surgical attire with two dangling earrings hanging outside of the bouffant hair covering.

Observation of OR #4 at 9:40 AM, OR #1 at 9:42 AM noted the Vendor and/or scrub tech (ST) in the operative suite with head and/or facial hair that was not contained within the head covering and/or mask.

Interview with the OR Manager at 9:42 AM on 9/17/19 noted that all hair must be contained within the head covering and the facility had hoods to cover facial hair.

The hospital's Surgical Attire policy identified that all personnel entering the semi- restricted and restricted areas of the surgical suites should confine all jewelry. The policy further identified that proper attire for the restricted area included a disposable hood for personnel with facial hair and bouffant hair covering.



c. A tour of the surgical suites in the main OR (operating room) was conducted on 9/17/19 and 9/19/19. Observation of OR #2 on 9/17/19 at 9:30 AM identified two areas of sticky tape remnants on the vinyl padding of the OR arm rest.

Observation of the endoscopy suite on 9/17/19 indicated two areas of sticky tape remnants on the vinyl covering of the procedure table. The sticky tape remnants rendered the equipment unable to be properly sanitized.

Interview with the Administrator of Surgical Services on 9/17/19 at 9:30 AM indicated that OR equipment was sanitized by using a lint- free cloth and Virex solution.

On 09/19/19 at 09:20 AM the surveyor, accompanied by a representative of the Engineering Department, observed during a tour of Operating Room #5 that there was a significant accumulation of dust and dirt on numerous horizontal surfaces throughout the entire room. Surfaces included "high reach" areas of door closer arms, door frame casings, cabinets, clocks. At the time of the survey, Operating Room #5 was functioning as an operating room with no indication of any current or past construction being conducted within this space to account for the accumulation of dust.

In addition, observed during a tour of Operating Room #5 that there was wall damage, peeling paint, and bare drywall surfaces, negating the ability to maintain a sanitary condition. At the time of the survey, Operating Room #5 was functioning as an operating room with no indication of any current or past construction being conducted within this space.

The hospital's environmental sanitation and OR policy for identified that prior to opening supplies for the first scheduled procedures of the day, all horizontal surfaces within the OR must be damp wiped. The policy further noted that end of day cleaning by environmental services included, in part, a thorough cleaning of furniture and equipment.



d. A tour of the OR and CPD was conducted on 9/17/19. Observations on 9/17/19 at 9:43 AM identified two steam sterilizers in the inner core of the OR of which one was deemed out of service. The observation further noted that the functional steam sterilizer had a build- up of rust on the door lip, flooring and shelving. Both sterilizers lacked signage for when the sterilizers were last cleaned.

Observations on 9/17/19 at 11:30 AM noted that the CPD department had two steam sterilizers. The insides of both sterilizer indicated a build- up of lime especially on the back wall. The sticker on the outside of each machine was faded and the readable portion of the date identified that cleaning was due 6/2019. Interview with the Director of Surgical Services on 7/17/19 at 9:43 AM noted that she did not consider having the two steam sterilizers cleaned by the company.

Interview with the CPD Supervisor on 9/17/19 at 1:30 PM indicated that he hadn't had the chance to schedule the company to clean/inspect the steam sterilizers. In addition, interview with the CPD Supervisor on 9/17/19 at 1:30 PM indicated that the sterilizer drains are rinsed daily although documentation of staff cleaning of sterilizers was lacking.

The hospital did not have a policy that identified how often the contracted company should clean/inspect the facility sterilizers, the sterilizer's manufacturer recommendations identified to reference the standards of AAMI (Association for the Advancement of Medical Instrumentation). The AAMI standard for preventive maintenance/general considerations identified that the manufacturer should provide written instructions for use for preventive maintenance of the equipment and the frequency of maintenance depends on how often the equipment is used.



e. A tour of the OR and CPD was performed with the Administrator of Surgical Services on 9/17/19. Observations on 9/17/19 at 9:43 AM identified two steam sterilizers in the inner core of the OR of which one was deemed out of service. Observations at 11:30 AM noted that the CPD department had two steam sterilizers.

Biological testing logs dated 9/1/19 through 9/19/19 were reviewed on 9/17/19 at 11:48 AM and indicated that daily biological testing was performed on the three sterilizers daily with the exception of 9/16/19.

Interview with the Covering Supervisor of the CPD on 9/17/19 at 11:48 AM noted that she saw that staff failed to document the testing on 9/16/19 and then had staff write in that they failed to test the sterilizers on 9/16/19. The manufacturer's recommendations for the sterilizers identified that a live spore test is the most reliable form of biological monitoring and recommended that the test be conducted daily to test the sterilizer.



f. A tour of the endoscopy suite was conducted with the Lead Technician on 9/17/19. Observations at 10:22 AM identified two scope storage closets in the department. The observations further identified that the closets were not vented. Interview with the Facilities Director on 9/17/19 at 10:43 AM indicated that the closets did not have to be vented because the pressure inside and outside of the closets were the same. The hospital's scope cleaning policy identified, in part, that the storage cabinet must be clean, dry and well ventilated



g. A tour of OR 2 was conducted on 9/17/19. Observations at 9:30 AM identified three spiked IV bags filled with IV fluid, hanging on a single IV pole and each IV tubing label noted 6:30 AM as the time in which the IV's were spiked.

Interview with the Anesthesia Technician on 9/17/19 at 9:30 AM noted that she spiked the IV's at 6:30 AM and the fluids would expire in 24 hours.

The hospital policy (per Lippincott) identified that if a solution is prepared outside the pharmacy, the administration should begin within 1 hour after the start of the preparation.



h. A tour of the surgical department was conducted on 9/17/19 at 9:13 AM. Observation in the anesthesia work room at 9:13 AM identified an opened multi-dose vial of Bupivacaine that lacked the date that the vial was opened and/or would expire.

Interview with the Administrator of Surgical Services on 9/17/19 at 9:30 AM indicated that the Bupivacaine vial is single use only (one patient) and should be discarded.

The hospital's general compounding policy identified that single use and multiple use vials will be labeled with the date and time that the vial was initially entered and initials of the person entering the container.



i. A tour of the surgical department was conducted on 9/17/19 at 9:13 AM. Observation at 9:45 AM identified three bottles of sterile water and two bags of lactated ringers IV solution in the fluid warmer. The bottles and IV fluid bags lacked the date that the items were placed inside of the fluid warmer.

Interview with surgical PCA (patient care assistant) on 9/17/19 at 9:45 AM noted that the items should be dated when placed in the fluid warmer and the fluids were probably placed in the warmer the prior night.

The hospital's policy for warming cabinets identified that solutions placed in the warmer shall be dated and removed after 72 hours.

The policy further identified that the solutions must be dated with the date they must be removed from the warmer.



j. A tour of the surgical department was conducted on 9/17/19 at 9:13 AM. Observation at 9:45 AM identified three medication refrigerators, two nourishment refrigerators, one freezer and one fluid warming cabinet within the surgical department. Review of the temperature logs for the refrigerators, freezer and warmer indicated that the temperatures were last monitored on 9/11/19 and were routinely monitored at 6:30 AM on operative days. The log was lacking documentation for 9/12, 9/13, 9/16 and 9/17/19.

Interview with the surgical PCA on 9/17/19 at 9:34 AM noted that a colleague usually monitored the temperatures every morning except on weekends.



k. Observation on the labor, delivery, recovery, and postpartum (LDRP) unit on 9/17/19 at 10:00 AM identified Environmental Services (EVS) Aide #1 and Environmental Services Aide #2 entered the semi-restricted area in the LDRP suite in street clothes without the benefit of shoe covers, or a surgical coverall suit. Employee #2's bonnet (hair covering) did not fully cover his head and exposed hair on the back of the head and above the ears could be visualized.

Interview with EVS Aide #1 on 9/17/19 at 10:00 AM identified he did not wear the clothing cover and shoe covers because he only went in to remove the garbage. EVS Aide #2 identified that he did not know that he was supposed to wear a clothing protector and shoe covers when entering the labor and delivery surgical suite.

Interview with Director #3 on 9/17/19 at the time of observation identified all staff who enters the semi-restricted area in the surgical suite should have hair fully covered by a bonnet, shoe covers, and hospital laundered scrubs or a coverall over their clothes to prevent infection.

The hospital's surgical attire policy directed personnel must wear clean surgical attire including caps and shoe coverings in semi-restricted areas of the operating room to provide an effective barrier that prevents the dissemination of microorganisms.



l. Tour of the LDRP suite with Director #3 and Manager #3 on 9/17/19 at 9:45 AM identified rusted, pitted castors on the IV pole in operating room #2. The rust prohibited the IV pole from being properly cleaned. Director #3 identified the surfaces and equipment in the operating rooms are cleaned after each case using hospital approved disinfectant.

The hospital's environmental sanitation and OR policy identified that end of day cleaning by environmental services included, in part, a thorough cleaning of furniture and equipment.

Based on observations during tour, review of hospital documentation, review of hospital meeting minutes and interviews, the hospital failed to ensure that environmental issues identified by the Infection Preventionist (IP) were also identified as Infection Control (IC) issues and not solely environmental repair issues. The finding includes:

A tour of the CPD was performed with the Administrator of Surgical Services on 9/17/19. Observations on 9/17/19 beginning at 11:24 AM identified multiple separated and/or broken areas of tile flooring in the sterile side of the CPD rendering the floor unable to be properly sanitized.

Review of environmental/infection control rounds dated 11/2017 through 6/4/19 identified that the CPD floor has had disrepair issues (therefore infection control issues) prior to 11/2017 that continued to present (9/17/19).

Review of infection control meeting minutes and interview with the IP on 9/18/19 at 12:00 PM identified that although she provided copies of the IC rounds to the VP of Patient Safety, CPD environmental issues were not discussed in the IC meeting minutes.

Interview with the IP on 9/17/19 at 2:51 PM indicated that the CPD received new tables and a washer and the floor repair had been deferred a couple of times.

The hospital's current infection control policy and plan identified a purpose of the IC program was to minimize the risk of development of health care associated infections and scope included identifying risks for the acquisition and transmission of infectious agents on an ongoing basis. The policy further noted that environmental rounds will be performed monthly, reported, in part, to the Environment of Care (EOC) committee and will be fully integrated into the Performance Improvement Plan and Program of the hospital.

The Patient Safety and Quality Assessment and Performance Improvement Plan identified that the EOC committee includes representatives from administration, clinical services and support services. The Plan further identified that the Committee monitors the safe practices of all of these groups and sends a report about safety management issues, in part, to senior management and the Board of Trustees.