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RAMAPO RIDGE BEHAVIORAL HEALTH HOSPITAL
INFECTION CONTROL PROGRAM
Tag No.: A0749
A. Based on observation and staff interview, it was determined that the facility failed to maintain a sanitary environment on two (2) out of two (2) inpatient psychiatric units toured.
Findings include:
1. During a tour of the geriatric psychiatric unit on 12/16/20, conducted in the presence of Staff #1 and Staff #2, the following was observed:
a. At 10:22 AM, exposed wood was visible under the window in Room #219. Exposed wood is not a cleanable surface. Staff #2 stated that Room #219 would be used as an isolation room for a patient with COVID-19 or a person under investigation.
b. At 10:28 AM, five (5) geri-chairs were observed in a hallway on the side of the nurse's station. All five (5) chairs had tears in the upholstery of the arms. Staff #2 stated that the chairs were in the hallway because they needed repair. Staff #2 stated that the repairs were not related to the upholstery.
(i) The arms of the chairs are not a cleanable surface.
c. At 11:00 AM and in Room #214, there was exposed wood on the arm of the chair, rendering it uncleanable.
2. During a tour of the adult psychiatric unit on 12/16/20, conducted in the presence of Staff #1 and Staff #2, the following was observed:
a. At 10:31 AM, black stains were observed along the floor of the shower in the "Shower Room."
3. The above findings were reviewed with Staff #1 and Staff #2.
B. Based on observation and staff interview, it was determined that the facility failed to implement infection prevention and control methods to prevent potential cross contamination in one (1) out of one (1) observation of blood glucose monitoring.
Findings include:
1. During an observation of blood glucose monitoring on 12/16/20 at 11:30 AM, Staff #9 brought a carrying case containing the glucometer, sharps container, and supplies into Room #223.
a. Staff #9 placed the carrying case onto the patient's bed and performed a blood glucose check. After performing the test, Staff #9 escorted the patient to a common area and returned the carrying case to the Medication Room. Staff #9 placed the carrier on the counter and proceeded to clean the glucometer. Staff #9 then placed the carrier in a cabinet without disinfecting the surface of the carrier that had been placed on the patient's bed.
2. The above was confirmed with Staff #9.