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Based on facility policy review, staff interview, observations made during facility tour, the facility failed to follow current facility policies related to cleaning Emergency Department treatment rooms, terminal cleaning of patient rooms, inventory control, and securing the housekeeping closet. This had the potential to affect all patients receiving care at this facility. The current census was 535 patients.

Findings include:

The facility policy titled "Cleaning Emergency Department Treatment Rooms" was reviewed on 02/01/18 at 10:25 AM. The policy instructed Environmental Services staff to high dust items above the shoulder including vents, lights and corners of walls. The policy further instructed staff to damp wipe sills, ledges, and other horizontal building and furniture surfaces with a germicidal solution to remove obvious soil. Furniture used for examination or treatment should be thoroughly damp wiped. The policy stated that in Emergency Room treatment rooms, the tops of the furniture and table should also be damp wiped between cases with germicidal solution. Staff are instructed to spot clean all glass to remove handprints, smudges, and other obvious oil. Non-carpeted floors should be damp mopped using a microfiber pad and a neutral detergent solution. The policy also instructed staff to restock all supplies including paper towels, toilet tissue, soap, and hand sanitizer.

The facility policy for inventory control was reviewed on 01/31/18 at 3:30 PM. According to the policy staff are instructed to check for expired products when putting away stock. Stock should be rotated from back to front ensuring the oldest product is pulled first.


1. The facility's Emergency Department was toured on 01/29/18 at 1:45 PM. Consult Room #1 and Consult Room #2 were observed from the lobby of the Emergency Department. The glass windows to the consult rooms visible from the lobby were covered with oily smudges and hand prints.

Triage Room #1 was toured. Prior to entering the room, Staff A, the Director of Emergency Services, identified the room as clean and ready for occupancy. Dust was noted on all horizontal surfaces in the room. A thick layer of dust was noted to fall to the floor when wiped.

A black sticky residue was noted on several areas on the floor. The sticky substance was identified as the leftover residue from the electrode pads placed on patients during the performance of electrocardiogram (EKG). It was reported that the electrode pads fall to the floor, leaving residueand over time people stepping on the residue turns the residue black.

A red substance was noted to be splattered on the wall of the triage room #1 and splattered on a laminated sign hanging just above a sharps container hanging from the wall. The red substance was easily removed from the laminated sign with a germicidal wipe. There was also a red substance noted on a white stool with wheels that medical staff sit on when interacting with patients. The soap dispenser was noted to be empty.

An area of rooms identified as SRU rooms were observed. Staff A revealed that SRU rooms are for the patients that appear most critical. SRU #1, the only empty room, was toured. A thick layer of dust was visible on all horizontal surfaces and equipment. A large red stain was observed on the privacy curtain in the room.

Staff A identified the ED room as a phlebotomy room where staff draw blood from patients presenting to the department. Two unlocked cabinets contained Vacutainer blood collection tubes (sterile glass or plastic tubes with colored rubber stoppers that create a vacuum seal inside of the tube, facilitating the drawing of a predetermined volume of liquid, vacutainer tubes may contain additives designed to stabilize and preserve the specimen prior to analytical testing)

Inside the cabinet, were 18 vacutainer tubes with gold rubber stoppers observed as expired. Five vacutainer tubes expired 04/2016, three tubes expired 12/2016, one expired 10/2016, one expired 11/2016, two expired 01/2017, four expired 08/2016, and two vacutainer tubes that expired 02/2017.

There were 10 vacutainer tubes with a lavender top observed as expired. Three vacutainer tubes expired 05/2017, three tubes expired 05/2016, one expired 11/2015, one expired 01/2016, one expired 02/2017, and one vacutainer expired 07/2017.

There were a total of 49 vacutainer tubes that were noted to be expired in the cabinet with blue, green,brown and red rubber stoppers.

The next cabinet contained 20 gauge intravenous catheters. Fourteen of the intravenous catheters expired 11/2017 and two intravenous catheters expired 10/2017. There were also two arterial blood sample syringes noted in the cabinet. They were both labeled with an expiration date of 09/2017.

These findings were confirmed with Staff A and Staff B on 02/01/18 at 10:45 AM.

2. On 01/31/18 at 10:45 AM 6NW, a 28 bed Medical Surgical unit, was toured. An unoccupied room was toured. Dust was noted on all horizontal surfaces in the room. Dust was noted to fall to the ground when wiped. Dust was noted in the vent inside the private shower in the room. The surface of the shower floor was noted to be peeling.

8NW, a 30 bed Hematology/Oncology unit, was also toured. A large plastic lid was noted to be wedged in the door of a Environmental Services closet allowing entry without a key. Staff B, the Manager of Environmental Services, reported that all Environmental Services closets should be secured.

8CCP, a 24 bed Transplant unit was toured. Room 8016, the only unoccupied room, was toured. The room was noted to be clean and ready for a patient. A red substance was noted on the blinds. A dried brown sticky substance was noted to be splattered on the wall. Dust was noted on all horizontal surfaces of the room. The bathroom was also toured. A brown sticky substance was noted on the white shower curtain in the bathroom. The shower curtain was actually a flat sheet used on beds. The sheet had been hung using safety pins.

Staff B, the Manager of Environmental Services, confirmed the findings and stated: "I don't know how this happened."

An Environmental Services duty list was reviewed on 02/02/18 at 11:45 AM. The duty list outlined tasks that Environmental Services staff are responsible for completing. Under the category of 'special instructions,' staff are instructed to secure housekeeping carts and closets at all times. Staff B was interviewed during tour and confirmed that it is the policy of the facility to secure all housekeeping closets.

The facility policy titled Terminal Dismissal Cleaning of Patient Room was reviewed on 02/01/18 at 10:15 AM. According to the policy every dismissal patient room is to be cleaned and sanitized promptly and ready for the next patient. Staff are instructed to high dust in a counter-clockwise motion using the high duster pole to high dust all surfaces, corners, lighting, TV, and vents above your shoulder height. These facts were confirmed with Staff B.

Based on medical record review, review of staffing and census records, facility policy review, and staff interview, the facility failed to follow Emergency Services policies and physician orders. The cumulative effect of these systemic practices had the potential to affect all patients receiving care in the Emergency Department.

Based on medical record review, facility policy review, and staff interview, the facility failed to ensure staff followed current facility policies related to performing suicide risk assessments and providing constant observation on suicidal patients and failed to follow physicians orders. This affected Patient #19, Patient #21, Patient #3 and Patient #17. A total of 23 records were reviewed. The current census was 535 patients.

Findings include:

1. The medical record of Patient #19 was reviewed on 02/01/18. The patient presented to the Emergency Department on 01/27/18 at 5:29 PM with complaints of a psychotic episode 2 weeks prior and a request for a psychiatric evaluation. The medical record lacked documentation a suicidal risk assessment was completed by staff.

The facility policy titled Initial Nursing Assessment was reviewed on 02/02/18 at 9:30 AM. According to the policy staff are required to perform suicide assessment within 1 hour after presenting to the Emergency Department. These findings were confirmed with Staff A on 02/01/18 at 11:00 AM.

2. The medical record of Patient #21 was reviewed on 02/01/18. The patient presented to the Emergency Department on 01/10/18 at 11:05 PM with complaints a suicide attempt. The patient reported jumping into a river in an attempt to harm him/herself. The patient had a history of depression. Although a sitter was noted to be at the bedside of the patient at 11:39 PM, the medical record lacked documentation the Patient Observation form was completed by staff. The patient was transferred to the Psychiatric unit at 02:52 AM.

The facility policy titled Suicide Precautions on the Non-Psychiatric Patient Care Unit was reviewed on 02/02/18 at 11:15 AM. According to the policy the patient monitor is required to complete a Constant Observation form that documents the patient's behavior every 15 minutes.

These findings were confirmed with Staff A on 02/02/18 at 11:30 AM.

3. The medical record of Patient #3 was reviewed on 01/29/18. The patient presented to the Emergency Department on 01/10/18 at 3:11 PM with complaints of a sickle cell crisis. Patient #3 stated: "I hurt all over in all my joints." A nurse determined the patient's acuity was a 2 (Emergent). Orders for labs were placed at 4:21 PM.

The medical record lacked documentation the ordered labs were completed.

The Patient Care Timeline revealed the patient was called from the waiting room for a ED room at 8:19 PM and it was discovered the patient had left without being seen.

Staff B confirmed these findings on 02/02/18 at 11:35 AM.

4. The medical record of Patient #17 was reviewed on 02/01/18. The patient presented to the Emergency Department on 01/29/18 at 7:05 PM with complaints of chest pain and anxiety. During Triage 1 at 7:07 PM the nurse determined the patient's acuity to be a level 3 (Urgent) using Emergency Severity Index (a five-level emergency department triage algorithm that provides clinically relevant stratification of patients into five groups from the least to most urgent based on acuity and resource needs. 1-resuscitation, 2- emergent, 3-urgent, 4-less urgent, 5-nonurgent).

Review of the ED record lacked evidence for the delay in vital signs and EKG for Patient #17 with reported chest pain. The record revealed Triage 1 was completed at 7:07 PM and EKG ordered at 7:51 PM.

An ED note by nurse documented at 7:53 PM, patient previously checked. Brought back to Triage room 2 for EKG and vitals by tech. Tech alerted this RN of abnormal EKG. Patient immediately transported to the shock resuscitation unit (SRU). The ED record lacked vital signs until 8:04 PM at which time the patient's heart rate was 147 beats per minute and his/her blood pressure was 127/99.

Per the ED Arrival process and Triage workflow policy number UCMC- CEC-SOP-006-02 policy the ED nurse performs Triage1 and tells the patient to have a seat in the lobby or sends them directly to the second triage.

Staff B confirmed these findings on 02/02/18 at 11:35 AM.