HospitalInspections.org

Based on observation, policy and procedure review, and staff interview, the facility failed to maintain the condition of the physical plant to assure the safety and well-being of patients by failing to ensure cleanliness of 1 of 1 (Sterile Processing Department [SPD]) area toured.

Findings:

1. While on tour of the SPD on 12/8/11 at 3:15 PM, accompanied by P5 and P12, the following was observed:
A. small amounts of paper garbage on the floor;
B. what appeared to be an instrument, such as tweezers, lying on the floor under a metal shelving unit used to store blue-wrapped surgical instrument packs;
C. packaged supplies and/or small bottles of liquid lying on their sides lying on the floor under a metal shelving unit used to store supplies;
D. dirt and grime caked around hardware screwed to the floor under the sink area;
E. some areas of the tile floors appeared to be soiled.
F. water spots and grime on the outside stainless steel surfaces of the cart washer and the sterilizers.

2. Policy No.: IC_01, titled "Infection Control Program Plan and Authority Statement" reviewed on 12/8/11 at 1:26 PM, indicated on pg. 2, under Function section, point 1.d., "The main elements of the Infection Control Program are surveillance, prevention and control of infection through monitoring, education and consultation...Providing consultation in the areas of policies and procedures for the prevention of infectious disease potential, infectious environmental health hazards...as well as review of cleaning schedules and procedures."

3. Policy No.: EVS_24, titled "Department Work Rules" reviewed on 12/8/11 at 1:26 PM, indicated on pg. 1, under Policy section, point A.12., "employees are required to clean all equipment at the end of the shift."

4. Environmental Services Duty List for Sterile Processing Department (SPD) reviewed on 12/8/11 at 1:42 PM, indicated personnel are to complete the following cleaning steps in all areas of the SPD on a daily basis: pull trash, high low dust, spot wash walls, disinfect horizontal surfaces, clean restroom and restock supplies, dust mop floor, inspect work, damp mop floor.

5. Personnel P12 was interviewed on 12/8/11 at 3:30 PM and confirmed, the SPD areas were not clean according to facility policy and procedure and had paper garbage, instruments, packaged items, bottles of liquid on the floor, and/or dirt and grime on the floor and edges of the floors in some areas. Also, employees are not cleaning the outside stainless steel surfaces of the cart washer and sterilizers at the end of each shift according to facility policy and procedure.