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Based on observation, interview and review of policies and procedures, it was determined the Facility failed to assure cleaning of furniture, floors, counter tops and equipment in the Emergency Department was performed per Facility Policy. The failed practice did not assure processes for cleaning and disinfection was integrated into the hospital standard policies and procedures and therefore cleaning and disinfection of surfaces could not be assured. The failed practice affected any patient treated in the Emergency Department. The findings were:

1) Observation on tour of the Emergency Department on 04/15/15 from 1400-1445, revealed: two bottles with blue liquid, one labeled as "NABC (Non-Acid Disinfectant Cleaner)" and one labeled as "Peroxy" on the counter in ER Room #2. RN #1 was asked what the product was used for and she stated "for our equipment and ". There was a cloth covered chair in the triage room that was soiled.
2) Housekeeper #1 was interviewed and stated the NABC was used for counters, walls and furniture disinfection and a Peroxy product is used on the floor. One of the bottles was labeled as Peroxy and was a blue color. Housekeeper #1 stated that it was mislabeled because the Peroxy product was clear, even though it was labeled Peroxy. The cloth furniture is cleaned when it looks dirty per Housekeeper #1.
3) The Environmental Services Director and Director of Maintenance Services reviewed the polices and procedures and manufactures directions for use and confirmed the following: the NABC product is for Bathroom cleaning; The super HDQ L 10 is to be used for hard non-porous services and allowed to remain wet for 10 minutes. Wet mopping is to be done with Super HDQL 10 as well.
4) Review of the Facility Policy "Cleaning supplies and chemicals" stated The Environmental Services Director and the Infection Control nurse will review all products intended for any level of disinfecting. Once the product is select for use, the Infection Control nurse will coordinate the review of the technical and material Safety Data Sheet on hospital grade disinfectant and tuberculosis by the Infection Control Committee and final approval prior to being put into use. Prior to the product becoming available to personnel for use, the Environmental Services Director will ensure the proper use and dilution procedure for the chemical is included in the Environmental Services Department continuing education program and all personnel are trained accordingly." The observations of the cleaning product and policies for use were confirmed at the time of observation by the Environmental Services Director.