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Based on review of policies and procedures, observation and interview it was determined the Governing Body failed to assure the Infection Control Program and the Environmental Services Department were effective in maintaining a safe and sanitary environment. The failed practices did not assure a safe and sanitary environment throughout the facility, assure sterile surgical instruments available for patient use were not expired and did not assure policies and procedures were followed. The failed practices had the potential to affect all staff, visitors and patients in the facility. (See CMS-2567, A747, A748, A749)

Based on review of policies and procedures, observation and interview, the Infection Control Officer failed to assure an Infection Control Program was maintained related to a sanitary environment; failed to follow policies and procedures for monitoring sanitation practices or maintaining cleaning schedules; and failed to assure the sterile integrity of surgical instruments. The failed practices did not prevent the spread of contamination throughout the facility related to dust, residue, poor condition of patient furnishings and unclean laundry practices and did not assure the sterility of instruments used in surgical procedures which had the potential to affect all patients, visitors and staff in the facility. Findings follow:

A. Review of Quality Control Policy 517.01 presented 09/21/12 revealed, "Monthly inspections are taken with department heads, nursing staff, and administrative staff ... 3) discover problems that were inadvertently overlooked by staff and management ... Supervisor Reports: each Environmental Service supervisor is required to submit a daily supervisor report. This documents the existing conditions and quality of housekeeping found during the supervisor's inspection in corridors and ancillary rooms, assists in planning project work and areas in need of improvement and employee training". A request was made to the Director of Quality for the monthly inspections and cleaning schedules for Environmental Services. No monthly inspections or cleaning schedules were presented for review. The lack of inspections and cleaning schedules was verified with the Director of Quality on 09/21/12 at 1255.

B. Review of Infection Control Policy 509-01 presented 09/20/12 revealed, "The Environmental Service Department will contribute to infection control practice within the facility. Participation includes but is not limited to the following:
I) Seven Step Cleaning Procedure,
II) Use, Cleaning and Care of Equipment,
III) Cleaning Procedures of Specialized Areas,
IV) Environmental Service Cleaning Supplies,
V) Maintenance of Cleaning Schedules,
VI) Evaluation of Cleaning Effectiveness,
VII) Communication with Infection Control Committee,
VIII) Personal Hygiene.
I. Seven Step Cleaning Procedure, A) Routine Daily Cleaning: 1. High Dust - ...wipe all high ledges including curtain rods, closets, tops of cabinets, tops of doors and vents. 2) Sanitizing and Spot Cleaning - ...damp wipe all horizontal surfaces and include telephones, furniture, door knobs, etc ... 6. Floor Sanitizing - wet mot floor with solution of disinfectant, 7. Visual Inspection. B) Terminal Cleaning: ...2. Wash Bed - ...damp wipe both sides of the mattress and wipe all surfaces of the bed frame including the side rails ... 4) Thoroughly wipe disinfectant from walls, furniture, window ledges, etc ...." A request for inspections and cleaning schedules was to the Director of Quality. No inspections or cleaning schedules by the Environmental Services Department were presented for review. The lack of inspections or cleaning schedules by the Environmental Services Department was verified with the Director of Quality on 09/20/12 at 1515.

C. Review of L&D (Labor and Delivery) Policy 512.01 presented 09/21/12 revealed, "Environmental Services Department will provide routine daily and project cleaning of the L & D and Nursery departments to control the spread of infections and to maintain the overall appearance of all public areas. ...7 Days per week ...clean L & D rooms using the Seven-Step cleaning procedures ....Nursery ...cleaning nursery spaces using the Seven-Step cleaning procedure on a daily basis, Isolettes, Bassinets and other Medical equipment to be cleaned by other personnel". A request for inspections and cleaning schedules was to the Director of Quality. No inspections or cleaning schedules by the Environmental Services Department were presented for review. The lack of inspections or cleaning schedules by the Environmental Services Department was verified with the Director of Quality on 09/21/12 at 1255.

D. A tour of the Operating Room was conducted at 1000 on 09/21/12 with the Operating Room (OR) Unit Manager, confirmed at the time and revealed the following:
1) Expired sterile instrument trays were on shelves, available for patient use and included:
a) Probe Hocky Stick expired 05/18/12;
b) Synthes Instruments and Screws expired 01/12/12;
c) Bariatric Hip Traction expired 01/13/12;
d) Rush Pins expired 06/14/12;
e) Non Locking Small Fragment expired 06/19/12;
f) Synthes Proximal Tibia expired 01/12/12;
g) Synthes Distal Tibia expired 10/21/11;
h) Stulburg Leg Holder expired 01/03/12 x 2 (Pack #1, Pack #2);
i) Bookwalter x 2 expired 05/25/12 and 05/23/12;
j) Supplimental Large Vascular x 2 expired 09/08/11 and 12/21/11;
k) Cusa Handpiece expired 04/12/12;
l) Tracheotomy Set expired 07/25/12;
m) Gastroenterology (GI) Tray expired 05/30/12; and
n) Bookwalter expired 07/10/12.

2) In OR #2 dust was observed on 2 Skytron units. Silk tape which is porous and cannot be cleaned was used to hold bins to Cart #18, tape was on a COW (computer on wheels) in OR #2, thick layers of dust was observed on 3 of 5 mobile Anesthesia carts in the sterile core.

E. A tour of the Emergency Services Department was conducted 09/20/12 from 1400-1430 and on 09/21/12 at 1220 with the Director of Quality and the RN (Registered Nurse) Charge Nurse on 09/21/12. Findings were confirmed at the time of the tours.

1) The following expired sterile instrument trays were on shelves, available for patient use and located in the Emergency Department:
a) ER (Emergency Room) Defibrillator Cord and Paddles x 2 expired 06/08/12
b) ER Large Basin expired 03/29/12
c) Major Laceration Set expired 06/08/12
d) Large Basin expired 08/08/12
e) Sheet expired 01/19/12
f) ER Orthopedic Set expired 07/19/12
g) Nursery IV x 2 expired 10/12/11 and 06/08/12
h) Tonsil Bleed set expired 06/08/12
i) ER Life Pack x 2 expired 06/08/12
j) ER Thoracotomy Set expired 10/12/11
k) ER Dental expired 06/08/12
l) ER Vaginal set x 2 expired 06/08/12

2) The connecting chairs in the waiting area contained an accumulation of dirt and grime at the connectors which did not assure they were clean.
3) The baseboards throughout the waiting area contained a thick accumulation of dirt and grime which did not assure they were clean.
4) The floor had an accumulation of dirt and grime in front of the chairs which did not assure it was clean.
5) The snack machine had an accumulation of dirt, grime and spider webs which did not assure it was clean.
6) The planter box contained red spots of an unknown substance and a buildup of dirt and grime which did not assure it was clean.
7) Multiple areas of the walls were stained with a dark substance which did not assure they were clean.
8) 24 of the 27 chairs contained tears and frayed edges exposing the porous inner fabric which cannot be disinfected.

F. Tour of the Emergency Department Clinical area was conducted on 09/20/12 at 0930-1000 with the Director of Quality. The following was observed and confirmed at the time of observation:
1) Trauma Room #9 suction canister exterior surface contained chalky white residue, a chair with tears and frayed edges exposing the inner padding which is porous and cannot be disinfected, and the stretcher bed contained tape residue which did not assure it was clean.
2) Trauma room #6 flooring was observed to have an accumulation of dirt and grime which did not assure it was clean.
3) The nurse's station contained areas in which the laminate was damaged exposing wood which is porous and cannot be disinfected.
4) Multiple supply bins contained clean supplies utilized for restocking the emergency rooms contained a buildup of grime and dirt which did not assure they were clean.
5) Multiple intravenous (IV) poles were observed to have an accumulation of dust on the base, rusty wheel casters, and tape residue which did not assure they were clean.
6) Clinic Room#13 contained a chair with tears exposing the porous padding which cannot be disinfected.

G. Tour of the Emergency Department's "Quick Care" Unit was conducted on 09/20/12 at 1000-1030 with the Director of Quality. The following was observed and confirmed at the time of tour:

1) The patient's public bathroom contained a buildup of dirt and grime under the raised toilet which did not assure it was clean.
2) The linen cart contained an accumulation of rust at the base which did not assure it was clean.
3) Exam Room #6 revealed an intravenous (IV) pole with an accumulation of rust on the base, the exam table padding contained a 3 inch tear, two of two chairs and a stool contained frayed edges and tears exposing the porous padding which cannot be disinfected.
4) The crash cart contained an accumulation of a brown unknown substance, tape residue and dust which did not assure it was clean.

H. A tour of the Labor and Delivery Department was conducted on 09/21/12 at 1235 with the Labor and Delivery Unit Manager, confirmed at the time and revealed the following:
1) Expired sterile instrument trays were on shelves, available for patient use and included the following:
a) D&C (dilate and curette) trays x 3 expired 06/02/12, 07/06/12, 07/19/12
b) Small Basin x 2 expired 01/09/12, 07/04/12
c) Large Basin x 7 expired 02/04/12, 11/20/12, 03/12/12 (x2), 02/04/12, 04/12/12 (x2)
d) OB (obstetrics) delivery set x 2 expired 08/10/12, 08/24/12
e) OB leg band x 4 expired 07/16/12, 08/17/12, 08/28/12 (x2)
f) OB bill tx (treatment) handle expired 02/12/12
g) OB prep (prepare) x 4 expired 12/01/11, 02/05/12, 03/20/12, 04/17/12
h) Forceps x 6 expired 09/20/12 (x6)
i) Forceps x 14 expired 02/04/12 (x12), 03/21/12 (x2)
j) Narrow Richardson expired 09/20/12

2) Tape residue was observed on three (3) warming units which did not assure they were clean; rips and tears were observed in three (3) basinet mattress pads exposing the fill which could not be cleaned or disinfected; a dusty electrical cord was observed draped across one bassinet which did not assure it was clean.

I. A tour of the Laundry Processing Department was conducted on 09/20/12 at 0835-1130 and 1400-1530 with the Director of Quality. The following observations were made in the Soiled Linen Sorting Room and confirmed at the time of the tour:
1) Employee #1 was observed stepping on linen on the floor soiled with feces and was not wearing shoe covers to prevent him from being contaminated or from potentially transmitting contamination throughout the facility when he left the department;
2) Employee #2 wore her personal protective equipment (PPE), fluid resistant gown open in the front exposing her clothing while sorting soiled linen which did not protect her clothing from becoming contaminated by the soiled linen.
3) Review of Laundry & Linen Policy, PPE in Soiled Sorting Area 702.1 presented 09/20/12 revealed, "PPE for eyes, face, head and extremities shall be provided, used and maintained in a sanitary and reliable condition. Whenever process, environmental, chemical, or biological hazards are capable of causing injury or impairment of any part of the body through absorption, inhalation, or physical contact, PPE shall be provided and used".
4) Review of Laundry & Linen Policy 203.1 presented 09/20/12 revealed, "All personnel must follow the PPE procedures as outlined in the infection control manual".

J. The following observations were made in the Clean Laundry Processing Room and confirmed at the time by the Director of Quality and Laundry Manager:
1) A cloth sheet, which is porous and absorbent, was observed on the floor in front of the "laundry presser and folder" machine; the Laundry Manager confirmed the sheet was "clean" and placed on the floor to allow clean linen to fall onto it to prevent the clean linen from touching the floor. Employee #3 was observed walking across the sheet on the floor.
2) Two laundry staff draped multiple pieces of clean laundry over their shoulders, and then together placed the linen on the conveyor belt of the "laundry presser and folder". As the two staff workers put the sheets through the presser, the bottom of the sheets were observed touching the floor which did not assure the laundry remained clean prior to being pressed and folded.
3) Employee #4 was observed manually folding gowns; the bottom of the gowns were observed to touch the floor as she folded them, which did not assure the linen was free of contamination.
4) The Clean Laundry Processing Room was observed to have a thick accumulation of dust and lint on exposed ductwork along the ceiling, laundry equipment, and on the floor; three of five laundry carts contained rust, peeling paint, and were stained with a dark brown substance of unknown origin; multiple areas along the walls were stained with a dark brown substance of unknown origin; the floor had an area of damaged tile. Lint/dust was observed falling from ceiling ductwork onto the presser/folder machine below. In an interview, the Laundry Manager, stated they did a "blow down quarterly and as needed" to remove dust and lint. He stated he had been in his role as Laundry Manager for two months, the blow down had not been done since he had been there and was not aware of when it was last performed. A request was made to the Laundry Manager for documentation of the last "blow down" but no documentation was provided by the facility during the survey.
5) Ductwork throughout the Clean Laundry Processing Room was observed to have breaks in the insulation exposing large holes along the ductwork as well as having no screens on the exhausts which blew directly over clean linen which did not assure cleanliness of the linen was maintained.
6) The "sheet folding machine" conveyor belts were stained with a dark brown substance which did not assure they were clean.
7) Underneath the "sheet folding machine" a thick accumulation of dark oily dust/lint was observed on the floor.
8) Review of Laundry & Linen Policy 101.1 presented 09/20/12 revealed, "It is the mission of the Laundry Department to ensure that the linens will be clean and orderly".
9) Review of Laundry Ceilings and High Equipment Tops Cleaning Policy 301.3 presented 09/20/12 revealed, "Purpose: To ensure the ceiling areas above the laundry production equipment and the tops of equipment are free from lint and dust ... Laundry Departmental employees are responsible for cleaning the ceilings and tops of high equipment quarterly ... Procedure: Designated employees will be scheduled quarterly to blow down the lint and dust from ceilings and the tops of high production equipment using air hoses and air wands".
10) The laundry facility was toured after the end of the shift with the Director of Quality. Twelve (12) carts of unprocessed linen were observed uncovered. Review of General Production Cleaning Policy 301.2 presented 09/20/12 revealed, "Laundry Departmental employees are responsible for coordination and cleaning of the clean side of production areas. At the end of the each daily shift, all soiled side employees will remove debris by: Picking up any items, sweeping the floor, removing trash and wiping the equipment ..., any linen not processed will be appropriately covered during this cleaning regimen. If necessary the floor will be mopped, but will at least be mopped once per week. The Laundry Manager stated the floor was last mopped "about ten days ago".
11) Review of Production Area Floor Cleaning Policy 301.4 presented 09/20/12 revealed "On a monthly basis, the environmental Services Department personnel will strip the existing coatings of wax off and re-apply new wax to the tiled areas in the production areas". The Laundry Manager stated he had been in his current role for two months; the floor had not been stripped or waxed since he had been there and was not aware of when it was last performed. A request was made to the Laundry Manager for documentation of the last "striping and waxing" but no documentation was provided by the facility during the survey.
12) Review of Laundry & Linen Policy 101.4 presented 09/20/12 revealed, "Purpose: to describe the hierarchy of accountability and responsibility within the Laundry Department and between the Laundry Department and Hospital Administration ....Laundry Department is under the direction of the Laundry Manager ...works cooperatively with other hospital departments toward achieving its goals and objectives and those of the hospital ...Laundry Manager is directly accountable to the Administrative Director of Support Services who is directly accountable to the Senior Vice President of Operations, who directly reports to the hospital President/CEO (Chief Executive Officer)".

K. A tour of the Pre-Op (Operative)/Pre-Procedure area was conducted on 09/21/12 at 0940 with the Pre-Op/Pre-Procedure Unit Manager, confirmed and revealed the following:
1) In room 1307, microfoam tape was holding the trim in place on the gurney and a thick layer of dust was observed on the bottom.
2) In room 1309, a thick layer of dust was observed on the bottom of two gurneys.
3) In rooms 1301 and 1302, a thick layer of dust was observed on the window sills.
4) A thick layer of dust was observed on the COW located in the hallway.
5) In the "Pantry" room utilized for patient nutrition, there was a brown crusty substance in the microwave and a white substance in the ice machine drain pan.

Based on review of policies and procedures, observation and interview it was determined the Infection Control Officer failed to identify, report and monitor the contaminated laundry, expired sterile surgical instruments availble for patient use and poor sanitation practices throughout the facility. The failed practice had the potential to affect all staff, visitors and patients in the facility. The findings follow:

A. A tour of the Operating Room was conducted at 1000 on 09/21/12 with the Operating Room (OR) Unit Manager. Findings were confirmed at the time of tour and revealed the following:
1) Expired sterile and included:
a) Probe Hocky Stick expired 05/18/12;
b) Synthes Instruments and Screws expired 01/12/12;
c) Bariatric Hip Traction expired 01/13/12;
d) Rush Pins expired 06/14/12;
e) Non Locking Small Fragment expired 06/19/12;
f) Synthes Proximal Tibia expired 01/12/12;
g) Synthes Distal Tibia expired 10/21/11;
h) Stulburg Leg Holder expired 01/03/12 x 2 (Pack #1, Pack #2);
i) Bookwalter x 2 expired 05/25/12 and 05/23/12;
j) Supplimental Large Vascular x 2 expired 09/08/11 and 12/21/11;
k) Cusa Handpiece expired 04/12/12;
l) Tracheotomy Set expired 07/25/12;
m) Gastroenterology (GI) Tray expired 05/30/12; and
n) Bookwalter expired 07/10/12.

2) In OR #2 dust was observed on 2 Skytron units. Silk tape which is porous and cannot be cleaned was used to hold bins to Cart #18, tape was on a COW (computer on wheels) in OR #2, thick layers of dust was observed on 3 of 5 mobile Anesthesia carts in the sterile core.

B. A tour of the Emergency Services Department was conducted 09/20/12 from 1400-1430 and on 09/21/12 at 1220 with the Director of Quality and the RN (Registered Nurse) Charge Nurse. Findings during the tours were confirmed at the time of the tours.

1) The following expired sterile instrument trays were on shelves, available for patient use and located in the Emergency Department:
a) ER (Emergency Room) Defibrillator Cord and Paddles x 2 expired 06/08/12
b) ER Large Basin expired 03/29/12
c) Major Laceration Set expired 06/08/12
d) Large Basin expired 08/08/12
e) Sheet expired 01/19/12
f) ER Orthopedic Set expired 07/19/12
g) Nursery IV x 2 expired 10/12/11 and 06/08/12
h) Tonsil Bleed set expired 06/08/12
i) ER Life Pack x 2 expired 06/08/12
j) ER Thoracotomy Set expired 10/12/11
k) ER Dental expired 06/08/12
l) ER Vaginal set x 2 expired 06/08/12

2) The connecting chairs in the waiting area contained an accumulation of dirt and grime at the connectors which did not assure they were clean.
3) The baseboards throughout the waiting area contained a thick accumulation of dirt and grime which did not assure they were clean.
4) The floor had an accumulation of dirt and grime in front of the chairs which did not assure it was clean.
5) The snack machine had an accumulation of dirt, grime and spider webs which did not assure it was clean.
6) The planter box contained red spots of an unknown substance and a buildup of dirt and grime which did not assure it was clean.
7) Multiple areas of the walls were stained with a dark substance which did not assure they were clean.
8) 24 of the 27 chairs contained tears and frayed edges exposing the porous inner fabric which cannot be disinfected.

C. Tour of the Emergency Department Clinical area was conducted on 09/20/12 at 0930-1000 with the Director of Quality. The following was observed and confirmed at the time of observation:
1) Trauma Room #9 suction canister exterior surface contained chalky white residue, a chair with tears and frayed edges exposing the inner padding which is porous and cannot be disinfected, and the stretcher bed contained tape residue which did not assure it was clean.
2) Trauma room #6 flooring was observed to have an accumulation of dirt and grime which did not assure it was clean.
3) The nurse's station contained areas in which the laminate was damaged exposing wood which is porous and cannot be disinfected.
4) Multiple supply bins contained clean supplies utilized for restocking the emergency rooms contained a buildup of grime and dirt which did not assure they were clean.
5) Multiple intravenous (IV) poles were observed to have an accumulation of dust on the base, rusty wheel casters, and tape residue which did not assure they were clean.
6) Clinic Room#13 contained a chair with tears exposing the porous padding which cannot be disinfected.

D. Tour of the Emergency Department's "Quick Care" Unit was conducted on 09/20/12 at 1000-1030 with the Director of Quality. The following was observed and confirmed at the time of observation by the Director of Quality:
1) The patient's public bathroom contained a buildup of dirt and grime under the raised toilet which did not assure it was clean.
2) The linen cart contained an accumulation of rust at the base which did not assure it was clean.
3) Exam Room #6 revealed an intravenous (IV) pole with an accumulation of rust on the base, the exam table padding contained a 3 inch tear, two of two chairs and a stool contained frayed edges and tears exposing the porous padding which cannot be disinfected.
4) The crash cart contained an accumulation of a brown unknown substance, tape residue and dust which did not assure it was clean.

E. A tour of the Labor and Delivery Department was conducted on 09/21/12 at 1235 with the Labor and Delivery Unit Manager, confirmed at the time and revealed the following:
1) Expired sterile instrument trays on shelves and available for patient use included the following:
a) D&C (dilate and curette) trays x 3 expired 06/02/12, 07/06/12, 07/19/12
b) Small Basin x 2 expired 01/09/12, 07/04/12
c) Large Basin x 7 expired 02/04/12, 11/20/12, 03/12/12 (x2), 02/04/12, 04/12/12 (x2)
d) OB (obstetrics) delivery set x 2 expired 08/10/12, 08/24/12
e) OB leg band x 4 expired 07/16/12, 08/17/12, 08/28/12 (x2)
f) OB bill tx (treatment) handle expired 02/12/12
g) OB prep (prepare) x 4 expired 12/01/11, 02/05/12, 03/20/12, 04/17/12
h) Forceps x 6 expired 09/20/12 (x6)
i) Forceps x 14 expired 02/04/12 (x12), 03/21/12 (x2)
j) Narrow Richardson expired 09/20/12

2) Tape residue was observed on three (3) warming units which did not assure they were clean; rips and tears were observed in three (3) basinet mattress pads exposing the fill which could not be cleaned or disinfected; a dusty electrical cord was observed draped across one bassinet which did not assure it was clean.

F. A tour of the Laundry Processing Department was conducted on 09/20/12 at 0835-1130 and 1400-1530 with the Director of Quality. The following observations were made in the Soiled Linen Sorting Room and confirmed at the time of the tour:
1) Employee #1 was observed stepping on linen on the floor soiled with feces and was not wearing shoe covers to prevent him from being contaminated or from potentially transmitting contamination throughout the facility when he left the department;
2) Employee #2 wore her personal protective equipment (PPE), fluid resistant gown open in the front exposing her clothing while sorting soiled linen which did not protect her clothing from becoming contaminated by the soiled linen.
3) Review of Laundry & Linen Policy, PPE in Soiled Sorting Area 702.1 presented 09/20/12 revealed, "PPE for eyes, face, head and extremities shall be provided, used and maintained in a sanitary and reliable condition. Whenever process, environmental, chemical, or biological hazards are capable of causing injury or impairment of any part of the body through absorption, inhalation, or physical contact, PPE shall be provided and used".
4) Review of Laundry & Linen Policy 203.1 presented 09/20/12 revealed, "All personnel must follow the PPE procedures as outlined in the infection control manual".

G. The following observations were made in the Clean Laundry Processing Room and confirmed at the time by the Director of Quality and Laundry Manager:
1) A cloth sheet, which is porous and absorbent, was observed on the floor in front of the "laundry presser and folder" machine; the Laundry Manager confirmed the sheet was "clean" and placed on the floor to allow clean linen to fall onto it to prevent the clean linen from touching the floor. Employee #3 was observed walking across the sheet on the floor.
2) Two laundry staff draped multiple pieces of clean laundry over their shoulders, and then together placed the linen on the conveyor belt of the "laundry presser and folder". As the two staff workers put the sheets through the presser, the bottom of the sheets were observed touching the floor which did not assure the laundry remained clean prior to being pressed and folded.
3) Employee #4 was observed manually folding gowns; the bottom of the gowns were observed to touch the floor as she folded them, which did not assure the linen was free of contamination.
4) The Clean Laundry Processing Room was observed to have a thick accumulation of dust and lint on exposed ductwork along the ceiling, laundry equipment, and on the floor; three of five laundry carts contained rust, peeling paint, and were stained with a dark brown substance of unknown origin; multiple areas along the walls were stained with a dark brown substance of unknown origin; the floor had an area of damaged tile. Lint/dust was observed falling from ceiling ductwork onto the presser/folder machine below. In an interview, the Laundry Manager, stated they did a "blow down quarterly and as needed" to remove dust and lint. He stated he had been in his role as Laundry Manager for two months, the blow down had not been done since he had been there and was not aware of when it was last performed. A request was made to the Laundry Manager for documentation of the last "blow down" but no documentation was provided by the facility during the survey.
5) Ductwork throughout the Clean Laundry Processing Room was observed to have breaks in the insulation exposing large holes along the ductwork as well as having no screens on the exhausts which blew directly over clean linen which did not assure cleanliness of the linen was maintained.
6) The "sheet folding machine" conveyor belts were stained with a dark brown substance which did not assure they were clean.
7) Underneath the "sheet folding machine" a thick accumulation of dark oily dust/lint was observed on the floor.
8) Review of Laundry & Linen Policy 101.1 presented 09/20/12 revealed, "It is the mission of the Laundry Department to ensure that the linens will be clean and orderly".
9) Review of Laundry Ceilings and High Equipment Tops Cleaning Policy 301.3 presented 09/20/12 revealed, "Purpose: To ensure the ceiling areas above the laundry production equipment and the tops of equipment are free from lint and dust ... Laundry Departmental employees are responsible for cleaning the ceilings and tops of high equipment quarterly ... Procedure: Designated employees will be scheduled quarterly to blow down the lint and dust from ceilings and the tops of high production equipment using air hoses and air wands".
10) The laundry facility was toured after the end of the shift with the Director of Quality. Twelve (12) carts of unprocessed linen were observed uncovered. Review of General Production Cleaning Policy 301.2 presented 09/20/12 revealed, "Laundry Departmental employees are responsible for coordination and cleaning of the clean side of production areas. At the end of the each daily shift, all soiled side employees will remove debris by: Picking up any items, sweeping the floor, removing trash and wiping the equipment ..., any linen not processed will be appropriately covered during this cleaning regimen. If necessary the floor will be mopped, but will at least be mopped once per week. The Laundry Manager stated the floor was last mopped "about ten days ago".
11) Review of Production Area Floor Cleaning Policy 301.4 presented 09/20/12 revealed "On a monthly basis, the environmental Services Department personnel will strip the existing coatings of wax off and re-apply new wax to the tiled areas in the production areas". The Laundry Manager stated he had been in his current role for two months; the floor had not been stripped or waxed since he had been there and was not aware of when it was last performed. A request was made to the Laundry Manager for documentation of the last "striping and waxing" but no documentation was provided by the facility during the survey.
12) Review of Laundry & Linen Policy 101.4 presented 09/20/12 revealed, "Purpose: to describe the hierarchy of accountability and responsibility within the Laundry Department and between the Laundry Department and Hospital Administration ....Laundry Department is under the direction of the Laundry Manager ...works cooperatively with other hospital departments toward achieving its goals and objectives and those of the hospital ...Laundry Manager is directly accountable to the Administrative Director of Support Services who is directly accountable to the Senior Vice President of Operations, who directly reports to the hospital President/CEO (Chief Executive Officer)".

H) A tour of the Pre-Op (Operative)/Pre-Procedure area was conducted on 09/21/12 at 0940 with the Pre-Op/Pre-Procedure Unit Manager, confirmed and revealed the following:
1) In room 1307, microfoam tape was holding the trim in place on the gurney and a thick layer of dust was observed on the bottom.
2) In room 1309, a thick layer of dust was observed on the bottom of two gurneys.
3) In rooms 1301 and 1302, a thick layer of dust was observed on the window sills.
4) A thick layer of dust was observed on the COW located in the hallway.
5) In the "Pantry" room utilized for patient nutrition, there was a brown crusty substance in the microwave and a white substance in the ice machine drain pan.

Based on review of policies and procedures, observation and interview, the Infection Control Officer failed to develop a hospital-wide system for identifying, reporting, investigating and controlling the spread of contamination in that policies were not followed and surveillance of causal factors of contamination were not documented. The failed practices had the potential to spread contamination throughout the facility via contaminated laundry, expired sterile surgical instruments available for patient use and poor sanitation practices. The failed practices had the potential to affect all staff, visitors and patients in the facility. (See CMS 2567, A747)