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Based on observation, review of policy and procedures for environmental cleaning, disinfection and interview, it was determined the Facility failed to assure disinfectants were used according to manufacturer's guidelines. It could not be assured a sanitary environment was maintained with disinfectant use inconsistent with manufacturer's guidelines. The failed practice affected one room observed (Room # 266) during the cleaning process on 02/14/12 and had the potential to affect all patient rooms cleaned by Environmental Services Employee #1. The findings follow:

A. On 02/14/12 at 1345, Environmental Services Employee #1 was observed cleaning a discharged Patient Room, #266. She stated she added the "disinfectant" to the mop water and used it to clean the room. On 02/14/12 at 1400 Environmental Services Employee #1 confirmed the product used was "TB Quat" on her cart. She used multiple cleaning cloths moistened with the spray cleaner to wipe surfaces in the room that included a piece of furniture, identified by the Director of Medical Surgical area, as a "couch" that had three discolored soiled areas on the cushioned seat surface. The surface of the couch was not sprayed with the TB Quat product and allowed to dry. The facility was unable to provide evidence the couch material was non porous and suitable for surface cleaning.
B. Review of the manufacturer's label and directions for use on 02/14/12 at the time of observation revealed the TB Quat product was a "Ready to use" product, not for dilution and formulated to disinfect hard, non-porous surfaces. Directions for use of the product stated "Spray area until it is covered with the solution. Allow product to penetrate and remain wet for 3 minutes."
C. The Facility Environmental Services Policy, Cleaning procedures for occupied and Discharged patient Rooms, Checkout Procedure, was requested on 02/14/12 and provided by the facility. The Policy stated "When cleaning furniture, damp dust back, seat, arms, legs, and sides of chairs. Damp dust inside and outside of overbed tables and bedside tables. Damp dust the top sides, and the interior of all closets, drawers in the room. Wipe furniture dry to prevent water spotting."
D. The Environmental Services Supervisor was interviewed on 02/15/12 at 1325 and confirmed the product Environment Services Employee #1 had used was a premixed TB Quat product and not for dilution.