HospitalInspections.org

Based on observations, interviews, and records review, the facility failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. The facility failed to:

A.) Ensure facility staff followed nationally accepted standards of infection control measures by not walking on the hallway with soiled gloves. Failure to ensure soiled gloves were removed and hands sanitized or washed with soap and water.

B.) Ensure Environmental Services/Housekeeping staff wore gloves when removing soiled linen and donning gloves when cleaning patient room after dismissal.

C.) Ensure clean linen were properly stored and covered to prevent cross-contamination.


D.) Ensure the floor in the medication room was properly mopped, medication cart and pixes were properly cleaned and kept free from dirt.


E.) Ensure trash was contained and emptied promptly.

These failures placed the patients at increased risk to their health by transmission of infections and contracting communicable diseases.

Findings included:

During a tour of the hospital 5th floor on 08/29/19 at 10:25 a.m. in the company of Nurse Supervisor Personnel #1, a staff member Personnel #2 was observed walking on the hallway with gloves on after coming from a patient room. Personnel # 2 thereafter removed gloves mid hallway and sanitized hands. This was confirmed by Personnel #1 who reported staff members were supposed to remove their dirty gloves and either wash hands or sanitize them using the hand sanitizers. She said, "he's not supposed to walk the hallway with gloves on."

Interview with Personnel # 2 on 08/29/19 at 10:30 a.m. revealed he was student volunteer in the facility. He stated he removed gloves and sanitized on his way to the whirlpool room. He said he was aware not to walk with gloves on the hallway but forgot to remove them.

Observation of the 5th Floor clean linen storage room on 08/29/19 at 10:45 a.m. revealed uncovered clean linen on top of a laundry cart. Cleaning rags were observed on the floor in the housekeeping janitors room. Trash was overflowing and had not been emptied in the unit. A cover matt was placed on the floor at the Nurse station. The floor in the medication room was dusty and had dirty brown-black markings. The medication cart was covered with dirt. These observations were confirmed by Personnel #1.

Observation on 6th floor on 08/29/19 revealed patient's refrigerator had undated opened milk. Dirty gloves thrown on the floor in the soiled utility room. Medication pixes top were covered with dust. Trash bins were overflowing and had not been emptied. These observations were confirmed by Nurse Manager Personnel #3.

Housekeeping Personnel # 4 was observed on 08/29/19 at 11:45 a.m. removing soiled linen from room 601 with no gloves on. She was observed mopping the floor and cleaning the room without gloves. Her linen cart was overflowing with dirty linen. A dining knife and a bottle of patient shampoo was observed in her cleaning water solution in her cleaning cart. These observations were confirmed by Personnel #3 and Personnel # 5.

Interview with Personnel # 4 on 08/29/19 at 11:55 a.m. through a Spanish interpreter (Personnel # 5) revealed she knew she was supposed to wear gloves but decided not to do so. She reported she was a contracted employee and said she was not sure whether she had been trained on infection control and transmission. Personnel #5 (Environmental services manager) reported he did not know whether she had been trained on infection control. He said, "she is supposed to be trained before working here but not sure since she is contracted."

Review of the Hospital policy titled "Environmental Services Infection Prevention" with an effective date 05/17 revealed in part... "gloves should be removed when leaving each patient room and hand hygiene should be performed."

Review of the Hospital policy titled "Hand Hygiene" with an effective date 03/19 stated in part... "Gloves should be used for hand contaminating activities."