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.
|GEISINGER MEDICAL CENTER||100 NORTH ACADEMY AVENUE DANVILLE, PA 17822||Dec. 3, 2019|
|VIOLATION: MAINTENANCE OF PHYSICAL PLANT||Tag No: A0701|
|**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on tour and observations, policy review and staff (EMP) interview, it was determined the facility failed to maintain a clean environment as observed in Abigail 5 Med/Surg ICU unit and HFAM8 unit; and clean the hospital in accordance with facility policy.
Review of hospital's "Cleaning Daily Occupied Isolation and Non-Isolation Rooms Procedure," last reviewed November 29, 2019.contained the following: "Procedure for daily occupied patient room isolation and non-isolation cleans ... 5. High Dust entire room including exterior surfaces of all vents; remove any debris hanging from ceiling including ceiling tiles ... 6. Gather cloth(s) and thoroughly moisten with approved disinfectant (sporacide for[DIAGNOSES REDACTED] cleans) to ensure proper manufacturer recommended dwell (wet contact) time ... 24. Dry mop and wet mop floors in patient area and restroom area doing room entrance last. ... Disinfect all horizontal surfaces including windowsills and ledges..."
Tour on December 2, 2019, at 10: 00 AM, of the Abigail 5 Med/Surg ICU Unit, revealed dust noted in the hallway on the floor, near the walls, in several areas measuring approximately a dime in size when gathered together, dust in a patient room near the supply cart measuring approximately a dime in size when gathered together, a blood sugar strip on the floor in two separate areas in the hallway, two soiled yellow spots on a ceiling tile in a patient room [Room A542], and several plastic cap items from syringes/intravenous fluid bags on the floor in two separate areas in the hallway.
Interview with EMP2 and EMP3 on December 2, 2019, at 10:05 AM, confirmed dust near the head of bed on wall by the medical gases and shelving units in patient rooms 876, 873, 859 and 852.
Interview with EMP3 on December 2, 2019, at 10:20 AM, confirmed a ceiling tile in a patient room, Room A542, had two soiled yellow spots noted on it. Further interview with EMP3 confirmed the yellow spot was unknown.
Interview with EMP2 and EMP3 on December 2, 2019, at 10:45 AM, confirmed a blood sugar strip was on the floor in the hallway outside of a patient room. EMP2 and EMP3 confirmed, at 11:10 AM, another blood sugar strip was noted on the floor in the hallway outside of another patient room.
Interview with EMP2 and EMP3 on December 2, 2019, at 10:55 AM, confirmed several plastic cap items from syringe or intravenous fluid bags were noted on the floor outside of two patient rooms.
Interview with EMP2 on December 2, 2019, at 11:00 AM, confirmed dust was noted on the floor in a patient room, near the supply cart located by the wall.
Tour and observations conducted on December 2, 2019, on HFAM building 8th floor between 10:45 AM- 11:10 AM revealed visible dust measuring approximately a dime in size when gathered together near the head of the bed on the wall by the medical gases and shelving units in patient rooms 876, 873, 859 and 852.
Interview with EMP8 and EMP9 confirmed visible dust in patient rooms 876, 873, 859 and 852.
Interview with EMP10 and EMP4 on December 2, 2019 at approximately 11:30 AM confirmed the environmental services staff were scheduled to clean patient rooms including high touch areas and horizontal surfaces daily with a disinfectant.
|VIOLATION: DISPOSAL OF TRASH||Tag No: A0713|
|Based on tour and observations, policy review, and staff (EMP) interview, it was determined the facility failed to promptly dispose of biohazardous waste.
Review of facility's "Infectious Waste Policy," last reviewed May 17, 2019, revealed: "Purpose: The Infectious Waste Policy establishes guidelines to reduce the risk of healthcare associated infections for patients, personnel and visitors. ... Policy: The Infectious Waste Policy/Regulated Medical Waste: ... 3. Complies with regulatory ... requirements related to the prevention and reporting of infections, including: a. Government regulations requiring appropriate segregation, packaging, labeling, and adequate containment of infectious waste in order to protect waste handlers and the environment from exposure. ... Procedure: 1. Basic Storage Requirements: a. Infectious waste must be stored and contained in a manner that: i. Maintains the integrity of the containers, prevents leakage or release of waste from the containers. ii. The containers are marked with prominent warning signs indicating the storage of infectious waste/regulated medical waste. ... b. Infectious waste must be placed in containers that are: i. Leak-proof. ii. Impervious to moisture iii. Sufficient strength to prevent puncturing, tearing or bursting during storage. iv. Labeled with universal biohazard symbol with the words "Biohazard, Regulated Medical Waste." v. Closed prior to removal to prevent spillage or protrusion of contents during handling, storage, transport, or shipping. ... c. Stationary regulated medical waste storage containers must be lined with the red bag for infectious waste..."
Tour on December 2, 2019, at 10: 00 AM, of the Abigail 5 Med/Surg ICU Unit, revealed in a dirty utility room there was a filled red biohazard bag sitting on the floor and the red biohazard container was overflowing with a filled red biohazard bag holding the red biohazard container lid open.
Interview with EMP2 on December 2, 2019, at 11:10 AM, confirmed the soiled utility room with a full red biohazard on the floor and the red biohazard container with a full red biohazard bag holding the red biohazard container lid open. EMP2 confirmed nothing is to be on the floor in the dirty utility room and the red biohazard container is always to have the lid closed. EMP2 confirmed when the red biohazard container is full, Environmental Services are notified so the container can be emptied.