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Based on observations, staff interviews and during the course of a complaint investigation it was determined the facility failed to ensure that two of two examination rooms were maintained in a clean and safe manner.

Findings include:

On November 9, 2011 at 2:30 pm, two Medical Facilities Inspectors (MFIs) accompanied by the facility's Chief Operating Officer (COO) and the Chief Nurse Executive (CNO), toured the facility's examination rooms, one located on the 5th floor and the other located on the 2nd floor. The examination room located on the 5th floor contained an examination table, a portable goose-neck light, wall cabinetry, base-cabinets, and multiple plastic bins which contained various supplies. The floor's carpeting had multiple large and small stains. The countertops were cluttered with supplies and dust was visible. The room did not contain access to a water supply for hand washing or potential patient hygiene needs following examinations. The room had an unclean, unkept overall appearance for an area in which patient examinations and/or procedures are provided. The examination room located on the 2nd floor contained an examination table, an infant scale on a cart, cabinetry, one sink and multiple plastic bins hanging on the wall which contained various supplies. A dried liquid stain of unknown origin was observed on the surface of a cart which held a computer-like monitor. The examination table had visible tears in the vinyl surface and dust which was visible and felt by one surveyor. A sharps container hung on the wall with dust visible which was also felt by another surveyor. A roll of replacement exam table paper was lying on the tiled floor. Visible dust was noted on the spiral rubber tubing connected to examination equipment hanging on the wall, (otoscope, ophthalmoscope and manual blood pressure cuff) in both examination rooms.

During the tour, the CNO stated that to his knowledge there were no scheduled or routine housekeeping tasks for either of the examination rooms. He explained the expectation would be that nursing staff would clean the examination table between patients and replace the exam table paper. The CNO and COO both acknowledge the findings as stated above. The CNO verified that both rooms were utilized by staff for patient procedures and examinations. He stated that the 2nd floor examination room was commonly used to start IVs (intravenous) on pediatric patients to prevent the child from associating their room with a painful procedure.