HospitalInspections.org

Based on observation, Infection Control Manual review and interviews, it was determined the facility failed to assure processes were in place and monitored to assure a clean and sanitary environment was maintained in classrooms, storage areas, recreation room, and that toy items for multiple patient use were cleaned. Failure to maintain a sanitary environment created the potential for the transmission of infection among patients. The failed practice had the potential to all 73 patients on census on 09/19/11 and all patients admitted to the facility. The findings were:

A. A tour was conducted with facility staff on 09/19/11 from 1230-1350. The following was observed:
1. The classroom area of the Adolescent Unit was observed with a thick accumulation of dust on the upper surfaces of the closed bi-fold doors. The cabinets along the walls were soiled on the outer surfaces. The wall area beside one of the doors in the classroom was discolored with black areas. The Environmental Services Director and Environmental Services Employee#1 were interviewed at 1300 and stated the desks and cabinet surfaces were to be cleaned every morning, then between 12 -1300 and the room was deep cleaned one time per week. The Environmental Services Director and Environmental Services Employee #1 confirmed the findings 09/19/11 at 1300.
2. The Clean Linen Storage Room, located off the "Honors Lounge," contained clean linen carts on wheels stored along the outer walls. Three dead bugs were observed under the first cart to the left of the entrance door. Dust had accumulated on the floor surfaces. The Environmental Services Director confirmed the findings 09/19/11 at 1310 and reported that housekeeping was responsible for cleaning the area.
3. The Adult Unit patient personal storage area contained individual patient personal items and plastic laundry baskets used by patients. One of four stacked laundry baskets was broken and soiled. The Clinical Services Director confirmed the findings 09/19/11 at 1345 removed the item and stated "They are supposed to be clean when they are put in here."
4. The recreation area was observed with six cushion mats stored on the floor of the room. The mats had frayed edges and cracks in the surfaces. The Clinical Services Director confirmed the findings 09/19/11 at 1340.
5. Two toy chests were observed in the Honors Lounge area. The toy chests each contained two toy items for multiple patient uses that were soiled. The Clinical Services Director stated in interview 09/19/11 at 1315 that the staff were supposed to clean the items after each use.
B. Facility policy "Disinfectant of Toys" dated 01/03, stated "When toys are brought into the hospital the toys must be wiped clean with a mixture of one-part bleach to ten-parts water (1:10) prior to the patient receiving that toy. Each toy whether individual or unit will be cleaned PRN (as needed) or at least weekly using the above disinfectant. This will be done by the unit staff under the direction of the team R.N."
C. Facility policy "Education: Employee Responsibilities" dated 01/03, stated "(#9) Each classroom will be vacuumed daily and chalkboards cleaned daily by housekeeping. (#10) Desktops will be dusted daily and wet washed at a minimum of once a week.
D. Review of the "Infection Control Surveillance Activity" report provided by the Infection Control Nurse on 09/19/11 for the period 01/11-08/11 revealed surveillance activities did not include observation of environmental services staff and cleaning process for classroom activities, linen storage areas and toy items.
E. On 09/22/11 at 1000, the Infection Control Nurse and Chief Nursing Officer were interviewed and all findings were reviewed. The Infection Control Nurse was asked by Surveyor #1 to describe environmental surveillance activities, he stated "I do spot checking when I'm on the floor and housekeeping (environmental services) also monitors for complaince." The Environmental services Director was interviewed at 1030, confirmed his department monitored housekeeping staff for compliance with housekeeping practices and stated "We have concentrated on the common areas."



30580

Based on review of Medical Staff Credentialing files and interview, the facility failed to ensure 8 of 13 Medical Staff had current TB (tuberculin) skin test results documented. The failed practice did not ensure staff, patients and visitors were not exposed to infectious disease and had the potential to affect all persons in the facility. Findings follow:

A. Review of 13 of 13 Medical Staff Credentialing files on 09/20/11 at 0850 revealed 8
(#1, #5, #6, #8-10, #12, #13) of 13 (#1-13) did not have evidence of current TB skin test results.
B. Findings were confirmed during an interview with the Director of Risk Management on 09/20/11 at 1320.