The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

LAKE CUMBERLAND REGIONAL HOSPITAL 305 LANGDON STREET SOMERSET, KY 42503 Feb. 24, 2011
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on observation, interview, and record review, the facility failed to implement policies to ensure a safe, sanitary environment to avoid sources and transmission of infection. The facility had a policy to provide a clean, sanitary, and orderly environment; however, the facility was not implementing their policy. Heating/air conditioning units were observed to be very soiled/dusty. Trash cans were observed to be soiled. The bottoms of chairs and doors were observed to be soiled/stained. A soiled IV pole was observed and floors were observed to be soiled.

The findings include:

During an environmental tour conducted on February 24, 2011, at 2:30 p.m., the following areas were observed to be in need of maintenance/housekeeping services:

1. The grids of the heating/air conditioning units in patient rooms 339, 340, 331, 404, and 433 were observed to be soiled with a heavy coat of dust.

2. The floors in patient rooms 331, 340, and 433 were observed to be soiled with bits of paper, mop string, pieces of soil debris, and scuff marks.

3. The doors in patient rooms 331, 404, 433, and 441 were observed to have stained, darkened areas on the lower portions of the doors.

4. The chairs in patient rooms 338, 340, and 404 were observed to be darkened and stained around all four legs of the chairs.

5. The trash cans in patient rooms 331, 340, 404, and 441 were observed to have dark stained areas around the bottom of the cans on the outside.

6. The overbed light in patient room 404 was observed to have a layer of dust on top.

7. The overbed table in patient room 433 was observed to have dried tan substance and debris on the base of the table.

8. The IV pole in patient room 331 was observed to have dried tan substance and debris on the base of the pole.

A review of the facility policies for "Patient Room Checkout Cleaning Procedure" and the "Seven Step Cleaning Procedure" revealed the staff was to clean all surfaces in each patient room daily and to inspect the room when finished to ensure all cleaning tasks were complete. There was no provision in the facility's policies for monitoring of cleanliness and sanitation by supervisory staff.

An interview with the Director of Housekeeping on February 24, 2011, at 2:30 p.m., revealed the Housekeeping Supervisor monitors an average of two rooms a week to check for cleanliness and sanitation. The Director further stated the facility had policies to ensure patient areas are clean and sanitary; however the staff was not cleaning according to the policy/procedure.