HospitalInspections.org

Based on observation, interview, and record review, the hospital failed to maintain a clean and sanitary environment in accordance with hospital policy and procedures and clinical standards of practice for infection control when:

1. "Brand name" analyzer machine (a portable, point-of-care (medical diagnostic tests that are performed at or near the site where the patient is receiving care) that provides rapid, comprehensive testing of patient blood samples to aid in critical care decisions) on multiple units in the hospital were visibly soiled with splatter marks, dark red in color, on the machine surface(s).

2. Medication, clean and dirty utility rooms (rooms designated to prepare and/or store clean supplies/medications and waste products separately) cabinets, on several units in the hospital had peeling labels and residual adhesive with built up debris stuck onto the adhesive.

3. Patient medication storage bins in the Intensive Care Unit (ICU- a specialized hospital department that provides critical care to critically ill or injured patients who require constant monitoring and intensive medical intervention) were visibly soiled with sticky, amber-colored substances.

4. Hot meals, breakfast trays containing scrambled eggs were stored in the Emergency Department (ED) nutrition pantry room counter and did not have a delivery date and time or a use by date and time label to warn of expiration.

These failures resulted in the potential risk of cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) to patients, visitors, and staff which could lead to infection and diseases.

Findings:

1. During a concurrent observation and interview on 11/4/25 at 9:53 a.m., during a tour of the Emergency Department (ED) with the ED Manager (MED) and Registered Respiratory Therapist (RRT) 1, the "brand name" analyzer machine in the medication room had dark red splash stains on multiple surfaces of the machine. RRT 1 stated the machine was used by Respiratory Therapists and the expectation was the surface of the machine should be wiped down with "brand name" wipes (disinfecting wipes) after each use. RRT 1 stated the machine needed to be cleaned.

During a concurrent observation and interview on 11/4/25 at 11:09 a.m. with the ICU Director (DICU), the ICU unit "brand name" analyzer machine had dark red splash stains on multiple surfaces of the machine. The DICU stated the machine needed to be cleaned.

2. During a tour on 11/4/25 at 9:53 a.m. on 2 South Medical/Surgical unit (Med/Surg - nursing units in the hospital where patients who are not critically ill are cared for) with the Director of Med/Surg (Dir M/S) and the Interim Manager (IM) of 2 South Med/Surg, the Medication Room was observed. The lower cabinet doors had a white substance that had dripped down the cabinet. The IM stated she did not know what the substance was, but the door did not look clean. The sink was observed to have a layer of white residue. The inside of the upper cabinet doors had multiple stickers that were peeling off, leaving a sticky adhesive residue. The IM stated the doors needed to be cleaned for infection control.

During a tour on 11/4/25 at 10:30 a.m. on 3 Med/Surg with Nurse Manager (NM) 1 and Dir M/S, the Medication Room was observed. The inside of the upper cabinet doors had multiple stickers that were peeling off, leaving a sticky adhesive residue. NM 1 stated the stickers should not be there and it was an infection control risk because it could not be cleaned. The dirty utility room (the room where equipment and supplies are stored after use and before being cleaned) was observed, and there were brown spots along the edge of the ceiling where the ceiling met the wall. Streaks were noted that appeared to be from something dripping down the wall. NM1 stated the wall needed to be cleaned.

During a concurrent observation and interview on 11/4/25 at 11:09 a.m., during a tour of the ICU, with the DICU, in the medication room, the inside of the upper cabinet doors had multiple stickers that were peeling off, leaving a sticky adhesive residue. The DICU stated the stickers were being removed and were to be replaced with new stickers, and it appeared the project was incomplete. The DICU stated his expectation was that the cabinets should be clean and free of debris to prevent cross-contamination.

3. During a concurrent observation and interview on 11/4/25 11:15 a.m. during a tour of the ICU medication room, with the DICU, patient medication storage bins had sticky debris collected on them. The DICU stated his expectation was the bins should be clean to prevent cross-contamination.

4. During a tour on 11/4/25 at 10:00 a.m. with the Director of ED (DED), the Emergency Department Nutrition Pantry room was observed to have a tray containing two (2) hot breakfast meals, intended for patient use, were stored on the counter. The breakfast trays did not have a use by or expiration date label or delivery date and time label. The DED stated without labeling to confirm the date and time of delivery, it was not possible to determine if the trays were safe to provide to patients. The DED stated the trays should have been thrown away.

During an interview on 11/5/25 at 1:53 p.m. with the Director of Infection Prevention (DIP), the DIP reviewed pictures taken during tours of hospital patient care units. The DIP stated the rooms were not clean and the stickers on the cabinets were not acceptable. The DIP stated the tape and stickers could not be cleaned and could cause cross contamination. The DIP stated her expectation was unit leaders should ensure staff were following policy and procedure (P&P) to maintain a sanitary environment. The DIP stated the analyzer machines and patient medication bins should be cleaned routinely and as per manufacturer recommendation.

During a review of the hospital's P&P titled, "Infection Prevention and Control Plan/Program (ICP Plan)," dated 6/18/25, the P&P indicated, "...PLAN: COMPLIANCE - KEY ELEMENTS...F. ICP Plan...1...The IPC Plan reflects:...l. Clean and sanitary environment that includes: ...iv. Medical equipment and medical devices..."

During a review of the hospital's P&P titled, "Sanitary Environment in Healthcare Facilities," dated 4/18/16, the P&P indicated, " ...POLICY SUMMARY/INTENT: The organization will maintain a sanitary environment to avoid sources of infection and communicable disease [define]. ...B....1. The methods of cleaning and/or decontamination [define] will be appropriate, effective and shall be appropriate for the: a. Location b. Type of surface or equipment c. Type of soil or contamination...3. Equipment and environment will be decontaminated between patients and after contact with blood or other potentially infections materials (OPIM), immediately or as soon as feasible, but no later than at the end of the shift this applies to: a. Surfaces that are overtly contaminated b. Spills of blood or OPIM c. When procedures are completed and d. At the end of the work shift if the surface may have become contaminated since the last cleaning... C....D. Manufacturer's instruction for use (IFU) for cleaning and maintaining medical equipment will be followed...L. Bins, pails, cans and similar receptacles intended for reuses shall be inspected and decontaminated regularly..."

During a review of the hospital's P&P titled, "Entity Plan: Bloodborne Pathogens [define] Exposure Control Plan," dated 3/19/25, the P&P indicated, " ...C. Methods of Compliance 1. Standard Precautions:... 5. Housekeeping: Environmental Services and Safety Management:...iii. a. Environment: i. Maintaining a safe, clean and sanitary environment for patients, visitors, and staff if part of the mission statement of the Environmental Services Department, as well as an important aspect of the Bloodborne Pathogens Standard..."
During a review of a professional reference from the Agency for Healthcare Research and Quality (AHRQ), an article titled, "Infection Prevention (IP)," (undated), the article indicated, " ... Providing a sanitary environment ... There is a clear separation of clean and dirty work areas. Clean areas are used for storage and preparation of medications and unused supplies; dirty areas are used for contaminated equipment ..."

During a review of the professional reference from Current Opinion in Infectious Diseases titled, "The role of the surface environment in healthcare-associated infections," dated August 2013, the article indicated, " ...Hospital surfaces are frequently contaminated with important healthcare-associated pathogens (bacteria). Contact with the contaminated environment by healthcare personnel is equally as likely as direct contact with a patient to lead to contamination of the healthcare provider's hands or gloves that may result in patient-to-patient transmission of nosocomial (originating from the hospital) pathogens ..."

During a review of the professional reference retrieved from https://www.who.int/publications/m/item/trs-1025-annex-7, an article titled, "Good Storage and Distribution Practices for Medical Products," dated 6/17/20, the article indicated, " ...Storage and distribution are important activities in the supply chain management of medical products ... Storage areas should be of sufficient capacity to allow orderly storage of the various categories of medical products ... Storage areas should be appropriately designed, constructed, maintained or adapted. They should be kept clean and there should be sufficient space and lighting ... Materials and medical products should be stored off the floor, away from walls and ceilings, protected from direct sunlight and suitably spaced, to permit ventilation, cleaning and inspection ... Materials and medical products should be handled and stored in such a manner as to prevent contamination, mix-ups and cross-contamination..."