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.

Based on review of facility policy and procedure, observation, and staff interview (EMP), it was determined the failed to ensure a safe and sanitary environment was provided for patients in the facility's Triage Room 7 bathroom.

Findings include:

Review on September 24, 2014, of the facility policy and procedure "emergency room Cleaning," dated revised December 2013, revealed "Purpose: The [sic] ensure the complete cleaning and disinfecting of Emergency Areas in accordance with Crothall's standard cleaning procedure ... Procedure: 1. Follow proper hand hygiene protocols. 2. Frequently touch base with Nurses Station to measure ED expected activity. 3. Follow Enhanced Discharge Cleaning Procedures from 7.02 of the EVS [environmental services] Policy and Procedure Manual and follow approved hand hygiene protocols. 4. Remove trash from patient suite. 5. High dust and disinfect vertical surfaces including doors, walls door knobs, light switches, IV poles, etc. 6. Disinfect horizontal surfaces including bed side tables, ledges, sink surfaces; dispensers. 7. Clean Privacy Curtain OR remove for cleaning depending on patient condition (isolation). 8. Fill Hand Soap and Towel if needed. 9. Dust mop floor. 10. Inspect work. 11. Damp floor surfaces with disinfectant using traditional or micro fiber process. 12. Ancillary areas to be cleaned per duty list to include but not limited to: a. Nurses Station b. Break Room c. Public Rest Rooms ... e. Play rooms f. Oxygen room g. Etc."

Review on September 24, 2014, of the facility policy and procedure "Ancillary Support Areas," dated revised December 2013, revealed "List of Areas: Radiology, Laboratory, Nuclear Medicine, Emergency, Pulmonary Function, Pharmacy, and Physical Therapy. ... Daily Restroom Cleaning: Stock supplies, and empty, clean and replace liners in wastebaskets. Using a germicidal solution, damp clean sinks, fixtures (pipes, vents, lights, mirrors, and dispensers), shower, toilet and urinals. Dust mop and damp mop bathroom floor (including corners, edges, behind doors and baseboards) using a germicidal solution."

An observation tour of the Emergency Department (ED) on September 24, 2014, at approximately 11:45 AM revealed the bathroom in Triage Room 7 had an accumulation of dust scattered under the radiator, the corners of the bathroom, and beneath the sink and around the toilet.

Interview with EMP3 on September 24, 2014 at approximately 12:10 PM confirmed the presence of dust scattered in the bathroom in Triage Room 7. EMP3 confirmed there was no documentation Triage Room 7 was cleaned.

Interview with EMP1 on September 24, 2014 at approximately 12:15 PM confirmed the presence of dust scattered in the bathroom in Triage Room 7.