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Based on observation and interview, it is determined that no notice of the contamination status of a decontamination room within the emergency department was posted, creating a safety issue for the entire hospital.

On October 24, 2013, an onsite Condition of Participation for Infection Control and Physical Environment was conducted. During a tour of the Emergency Department (ED) at approximately 9:45 am, a decontamination room off of the ED was noted through the doors ' glass window, to contain a gurney and multiple folding privacy screens (5-6), apparently in storage there.

When the RN began to go into the room she stopped and stated that the room had been used to decontaminate a patient that morning of bed bugs. The RN was not sure if the room had been decontaminated or terminally cleaned as yet. Nonetheless there was storage in the room.

There was no signage or other means to determine the status of the room. When the surveyor inquired, the nurse noted that there is no specific procedure by which staff are notified of the decontamination room's status or if it had been terminally cleaned , other than contacting the charge nurse. Therefore, if an employee went into the decontamination room to get one of the privacy screens stored there, or if the gurney was used for another patient without first checking with the charge RN, there would be a risk of transporting bed bugs to other parts of the ED or the hospital. Additionally, the work required to terminally clean the decontamination room was increased by virtue of the multiple items now stored in the room.

Further questioning of the ED staff on 10/24 revealed that in fact, the room had not yet been decontaminated, though the patient had required its use approximately two hours prior to the surveyor's tour of the area. Based on this information, the hospital failed to maintain clean and safe storage of equipment.