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.

SAINT JOSEPH EAST 150 NORTH EAGLE CREEK DRIVE LEXINGTON, KY 40509 Nov. 18, 2015
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview, medical record review, and review of facility's policy, "Discharge Cleaning (Standard Patient Room)", it was determined the facility failed to ensure its room cleaning procedure after patient discharge was followed for one (1) of ten (10) sampled patients, Patient #1.

The findings include:

Review of facility's policy, "Discharge Cleaning (Standard Patient Room)," Policy Stat ID: 3, effective date 08/2010, revealed the seven (7) step cleaning process was performed after patient discharge to make the room clean, sanitary and safe for the next patient being admitted to the room. The policy further revealed four (4) of the seven (7) steps were; 1) sanitizing and spot cleaning all ledges, furniture, bed, phone, and fixtures using a bleach disinfectant; 2) bathroom cleaning using a hospital approved disinfectant; 3) wet mopping all hard tile floor areas; and 4) inspection of the room to ensure the room had been cleaned correctly.

Review of Patient #1's medical record revealed Patient #1 was admitted on [DATE] at 9:36 PM with diagnoses including Intrauterine Pregnancy at Term (thirty-nine (39) weeks gestation). Further review revealed Registered Nurse (RN) #1 was the admitting nurse, and Patient #1 was admitted to a labor/delivery/recovery (LDR) room. The record then revealed Patient #1 had a spontaneous vaginal delivery on 09/23/15 at 4:36 PM of a viable infant with a one (1) minute Apgar score (a score from one (1) to ten (10) used to evaluate the status of the infant at birth with a lower score indicating compromised health status) of nine (9) and a five (5) minute Apgar score of nine (9). Patient #1 had no complications and was discharged from the facility on 09/25/15.

Interview with Registered Nurse (RN) #1, on 11/18/15 at 3:47 PM, revealed when she admitted Patient #1 to a LDR room there were two (2) to three (3) spots of dried blood, each smaller than a dime, on the floor of the room. She also stated, on the bathroom wall next to the toilet, there were three (3) to four (4) spots of blood that had dripped down about two (2) inches each that were very close to the floor, almost to the bottom of the wall. RN #1 also revealed she cleaned each spot with a bleach wipe and informed the charge nurse who was to notify housekeeping of the incident.

Interview with the Environmental Services Manager, on 11/17/15 at 11:00 AM, revealed a worker from the Housekeeping Department cleaned all the LDR rooms. He also revealed there was one (1) housekeeper assigned to that area on all days of the week from 7:00 AM to 11:30 PM.

Interview with the Environmental Services Manager, on 11/18/15 at 10:47 AM, revealed Housekeeper #1 was the housekeeper who had cleaned Patient #1's LDR room prior to admission. He also revealed Housekeeper #1 was off work until February 2016 and could not be reached for interview.

Interview with the Environmental Services Manager, on 11/18/15 at 4:34 PM, revealed there was an obvious lack of service for Patient #1 by Housekeeper #1 with the missed sanitizing of the bathroom wall, the missed mopping of the blood drops on the floor in the LDR room, and the inspection of the room to ensure its cleanliness. He further stated this should not have occurred, and Housekeeper #1 violated the facility's policy on cleaning of rooms after patient discharge.