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Based on observation and interview the infection control officer failed to develop, implement and evaluate measures to insure that cleaning cloths, disposable or reusable, were changed between rooms being cleaned in 1 of 1 rooms observed and 2 of 2 staff interviewed. Based on observation, record review, and interview, the facility failed to assure expired medications were removed from the patient care area. Two of four insulin vials in a patient medication refrigerator were expired. The facility also failed to have a process for a daily assessment for necessity to continue central venous catheters.



On 9/26/2011 at 11:00 AM house keeping staff was observed terminally cleaning a patient room on the medical surgical unit. The wand used to wipe down the walls was covered with a yellow disposable cloth. The surface of the cloth was "pill rolled" as is it had been used prior to cleaning the room. The house keeping staff was interviewed and confirmed that the cloth was changed periodically throughout the day.

On 9/26/2011 at 2:00 PM house keeping staff was interviewed and asked "how often do you changed the yellow cover on the wand used to wipe down the walls?" The staff answered every 2-3 rooms.

On 9/26/2011 at 1:00 PM an interview of the house keeping supervisor revealed the policy and procedure manual did not specify when to change the wand covers when cleaning a patient room.

On 9/26/2011 at 1:15 PM the Infection Control Officer confirmed the housekeeping policy for cleaning of patients' rooms did not include the needed instruction.

During a facility tour on 9/26/2011 at 9:30am, two vials of insulin found in the patient refrigerator on the medical-surgical unit were expired. One vial expired on 9/25/11 and the other expired on 8/25/11. Staff #5 confirmed these findings and discarded the vials.

Review of infection control policies revealed no evidence of a daily assessment for necessity to continue central venous catheters. During an interview on 9/27/11 at 10:00am in the quality manager ' s hallway, staff #4 confirmed that no daily assessments were made regarding the necessity to continue central venous catheters.