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Based on observation, record review, and interview the facility failed to ensure that staff maintained a sanitary environment to mitigate potential infection control risks; and failed to ensure unit staff (RNs/ PCTs) are trained on policies and procedures for cleaning/disinfecting patient care areas contaminated and/or potentially contaminated with bodily fluids. This failure to ensure a sanitary environment and staff education has the potential to affect all patients, unit staff, and visitors in the hospital.


Findings Include:

The facility failed to ensure that staff maintained a sanitary environment to mitigate potential infection control risks in 2 of 2 patient care units observed (Petersik Hall North, Petersik Hall South), and failed to ensure that 12 of 12 RNs and 38 of 38 PCTs who are expected to complete housekeeping duties are trained on policies and procedures for cleaning/disinfecting patient care areas contaminated and/or potentially contaminated with bodily fluids. See Tag A-0749.

Based on observation, record review, and interview the facility failed to ensure that staff maintained a sanitary environment to mitigate potential infection control risks in 2 of 2 patient care units observed (Petersik Hall North, Petersik Hall South), and failed to ensure that 12 of 12 RNs and 38 of 38 PCTs who are expected to complete housekeeping duties are trained on policies and procedures for cleaning/disinfecting patient care areas contaminated and/or potentially contaminated with bodily fluids (i.e. feces and urine).

Findings include:

Review of policy and procedure titled, "Sanitation, Housekeeping" last reviewed 12/2020 revealed the following:
1. All staff who use a product will receive training on the use of all new products.
2. The Infection Control Practitioner or Nurse Manager shall communicate with the housekeeping Services Supervisor whenever an area is in need of contamination cleanup.
3. Protective clothing such as a mask, gown, goggles, and gloves, is available and must be used when cleaning contaminated areas.
4. Contaminated room cleaning shall be done with special attention to the following sequence of tasks:
a. Clean from top to bottom--ceiling, walls, sills, furniture, and floor.
b. Starting at the door, clean in counterclockwise rotation.
c. All items/areas shall be cleaned with disinfectant, following manufacturer's instructions and dilution rates.
6. Housekeeping shall be trained at least annually in the policies and procedures concerning cleaning and safety/health precautions of areas that may have been contaminated by an infectious process.
7. The clinical person in charge of an area or of a patient is responsible for critical body fluid cleanup. Housekeeping shall sanitize with disinfectant after body fluid has been cleaned up. Proper sanitization means the recommended product is used and the product is left on the surface for the amount of time required on the product label.

Review of the "Sanitation, Housekeeping" policy revealed the following cleaning requirements:
Seclusion Rooms:
1. The PCT (Patient Care Technician) shall, after each use using disinfectant clean the following:
a. Mop Floors
b. Spot wash the walls
c. Wipe up patient body fluid spills.
d. Wash the common floor areas between seclusion rooms.
Patient Rooms:
1. Unit Staff responsibilities (PCTs and Registered Nurse) when patient is discharged:
a. Wipe bed and bed frames
b. Clean wardrobes
c. Wash and disinfect mattress
d. Clean mirror, shelving, and furniture
Dayrooms:
1. Unit staff responsibilities:
a. Daily--wipe table tops and dust and clean furniture

Bathrooms and Shower Rooms:
1. Thorough bathroom and shower cleaning in patient areas is the responsibility of housekeeping except when it is completed by unit staff on weekends and holidays. Also, messes made spontaneously throughout the day are to be cleaned by unit or area staff.
a. Bathroom and shower rooms shall be cleaned daily; including toilets, urinals, sinks, walls, floors, mirrors, and ceilings shall be inspected.

Per "Sanitation, Housekeeping" policy, "Classes for cleaning and infection control, such as cleaning contaminated areas, shall be held periodically."

Review of the facility "Infectious Disease Policy 208.01" (no date) revealed staff should "Wear gloves, wear a face shield and gown when working with infectious blood or body fluids with all disinfectants." Per policy, Virex Plus (disinfectant) needs the following surface "Contact Wet Time" to be effective:
-1 minute contact time: HIV (Human Immunodeficiency Virus), Influenza A
-3 minute contact time: Covid-19, MRSA (Methicillin-resistant Staphylococcus Aureus), Hepatitis, E-coli (Escherichia coli).
-5 minute contact time: Norovirus

Observations while on a tour of Petersik Hall North and South with Director A, Manager B, and Manager E on 01/10/2022 from 11:30 am to 2:15 pm, revealed the following:

-The patient bathroom (room # unknown) smelled like urine, per observations the floor was wet in front of the toilet leading to the door of the toilet stall. Per interview with Manager B on 01/10/2022 at 12:00 pm, Manager B stated staff should check the bathrooms after each patient use and immediately clean up any signs of contamination (i.e. urine).
-The unoccupied Seclusion Room (S302) contained brown residue smeared on the wall and on the mattress; the floor contained gum-like material smashed and stuck onto the floor. Per interview with Manager E on 01/10/2022 at 2:10 pm, Manager E stated that the Seclusion room "should be clean but it's not."
-The Shower room (S343) contained black colored residue on the floor surrounding the stainless steel shower stall separator.
- The patient bathroom (S342) contained a clogged sink with a large amount of brown particles floating in the standing water.
- An unoccupied "clean" patient room (S339) contained dust/debris and pink writing on the floor.
- The hallway of unit contained quarter sized dark brown material smashed and stuck onto the floor.
- An unoccupied "clean" patient room (S335) contained dust/debris, yellow residue/staining, and grayish colored material smashed and stuck onto the floor.
- The Shower room (S305) contained black colored residue around the shower drain and brown colored residue/staining on approximately 30 ceiling tiles.
-The Multipurpose room (S307) contained sticky residue on the floor and clumps of dust in the corners around the room.
-The bathroom (S304) contained a roll of tissue paper sitting directly on floor; there was a large amount of brown/tan residue on the floor behind the toilets; and there was brown residue/staining on the wall tile under the bathroom sink.

Per interview at the time of the tour, Manager B, Manager E, and Treatment Director A stated that they did not know what the brown and black residue was or how it got there.

-The Shower room contained a shower curtain hanging from a shower stall. Per interview with Manager B on 01/10/2022 at 1:00 pm, Manager B stated that housekeeping staff do not have a routine schedule for cleaning of the shower curtain and that the shower curtain is cleaned as needed; Per interview with Manager B there was no documented evidence of shower curtain cleaning.

-Observed a layer of dust and small particles of debris on the bed frame housing the mattress and on the shelving used for patient clothing in an unoccupied patient room (N217). Per interview with Manager B at the time of the observations, the room was previously cleaned by unit staff. When asked how Manager B knows if the rooms have been cleaned after a patient discharges, Manager B responded that the staff should be writing "clean" on the chalk board outside of the patient room. Per Manager B, staff do not document room cleaning anywhere else. Per observations room N217 did not have "clean" written on the chalk board outside the room.

Per interview with Manager E on 01/10/2022 beginning at 2:00 pm, when asked how staff know when a room is cleaned after a patient discharges on his/her unit, Manager E stated that the curtain covering the outside of the door window is "turned sideways" by unit staff. Manager E stated, "Patients can move the curtains so it's not a perfect system." Per Manager E, staff do not document when a room is cleaned after a patient discharges to ensure a new patient is going into a "clean" room.

Per interview with Manager B on 01/10/2022 at 1:45 pm, Manager B stated that a work order was opened for the clogged sink containing sitting water and brown material (S342) in the patients bathroom.

Per review of the Work Request revealed a work order was placed on 01/05/2022 at 12:24 pm and had not been completed at time of observations (5 days later).

Per interview with Management Service Director G on 01/11/2022 at 2:24 pm, Director G stated that the work order was assigned to Facility Maintenance Specialist H, however he/she unexpectedly was unable to come to work and the work order was never reassigned. Per Director G, the work order should have been reassigned and addressed the same day due to the plumbing issue occurring in a patient care area.

Per interview with PCT F on 01/11/22 at 10:10 am, PCT F provided care for a patient who had an issue with defecating and urinating on the floor in his/her room; PCT F stated that she/he cleaned up the feces and urine in the patient's room and used a broom and dust pan to remove the feces. When asked what PCT F did with the broom and dust pan after using it to dispose of feces, PCT F stated that she/he rinsed it off and applied disinfectant. Per interview, PCT F stated she/he did not use a gown while cleaning up Pt #7's urine and feces (as per policy). Per interview with PCT F, she/he used Virex Plus to disinfect Pt #7's floors, the broom, and the dust pan; when asked how long the contact time should be for the disinfectant to be effective, PCT F stated that she/he was "not sure." Per interview with PCT F, the unit staff are required to clean discharged patient rooms; the shower/bath room and day room on weekends and holidays, and as needed during the shift. Per F, he/she has not had any formal training on the policies and procedures regarding the cleaning process and safety precautions of areas contaminated with bodily fluids (urine,feces,blood). Per PCT F he/she has been working at the facility for 18 years and just knows what to do.

Per interview with Deputy Director D on 01/11/2022 at 3:00 pm, Director D stated that Virex Plus disinfectant should sit on surfaces for a minimum of 5 minutes when cleaning surfaces contaminated or potentially contaminated surfaces.

Per interview with Director of Nursing (DON) C on 01/10/2022 at 4:00 pm, DON C stated that unit staff (RNs/PCTs) share cleaning responsibilities with Housekeeping staff, and are required to clean discharged patient rooms and occupied patient rooms as needed (i.e. urine/fecal contamination), patient showers and bathrooms on weekends and holidays and as needed (i.e. urine/fecal contamination). Per interview with DON C, Housekeeping staff receive training/orientation on the cleaning policies and procedures of contaminated patient care areas, but the unit staff (RNs/PCTs) do not receive this training/orientation. Per DON C she/he has been asking for the unit staff to receive this training "but it has not happened yet."