HospitalInspections.org

Based on observations, interviews, and review of policies and procedures, the Long Term Acute Care (LTAC) Hospital failed to maintain a clean and sanitary environment for patients as evidenced by:
1. Supplies from previous patient left in a cleaned room
2. Brown substance on chair tray in a clean room
3. Splatters on the walls
4. Dark substance on bed rails
5. Broken Formica around sink areas
6. Caulking around sink and counter tops missing or bubbly
7. Cobweb behind television area
8. Clothing on floor of hall shower
9. Baseboards missing

These concerns had the potential to affect all patients of the facility.

Findings include:

Policy and procedure:
"Standard Room Cleaning Procedure
Supersedes: 8/1/2009
Purpose: To ensure the complete and systematic daily cleaning of each patient/ resident room ... Procedure: ... 3. High dust, beginning at the entrance and working around the room in a circle. ... 4. Using germicidal cleaner and a clean cloth, sanitize all patient contact surfaces, including overbed table, bedside table, phone, chairs, low ledges and counter, light switches and door knobs. ... 5. Spot wipe stains and spots from walls and other vertical surfaces.

Discharge Room Cleaning Procedure
Supersedes: 8/1/2009
Purpose: To ensure the complete cleaning of the discharge patient room in accordance with ... standard cleaning procedures.
Purpose: ... 4. Using germicidal cleaner and a clean cloth, sanitize all patient contact surfaces, starting with the bed. Wipe the top and sides of the mattress. Beginning at the head of the bed, fold mattress in half and clean the underside of the mattress, springs and frame. Repeat process with the foot of the bed. Clean the head of the bed, moving to the bed rails and bed controls, then the foot of the bed and opposite side bed rails. Using the bed controls, raise the head and foot of the bed. Clean the underside of the bed beginning with the springs and clean all under parts of the bed. Clean wheels, removing all strings and debris, using putty knife if necessary. Proceed to clean overbed table, bedside table, phone, chairs, low ledges and counter, light switches and door knobs. ... 5. Damp wipe stains and spots from walls and other vertical surfaces. 6. When encountering significant body fluids, please follow the approved hospital guidelines.. Generally heavy body fluids, including but not limited to blood, feces, etc. are handled by the clinical staff with support from EVS (environmental services). ... 8. ... spot clean walls around sink area."


Observations on 7/2/12 at 10:15 AM
Room 801 - Sticky substance on right bedrail, brown splatter on wheels of bed and brown substance on bottom bed rail

Observations on 7/2/12 at 10:40 AM
Included:
Room 801 - Ventilator supplies left in room from previous patient. These supplies were not removed prior to cleaning room. Employee Identifier (EI) # 1, Director of Clinical Services (DCS), verified the supplies were supposed to be removed from the room prior to cleaning.

Observations on 7/2/12 at 10:50 AM
Included:
Room 867 - Clear looking Splatters on wall behind chair, baseboards away from wall or missing. Cobweb and dust in corner behind television.
Common Shower area- a shirt was on the floor and an unopened bar of soap.
Room 862 - Broken and missing Formica sink area, caulk around sink area missing or bubbly looking.
Room 860 - Tray in closet with brown substance drip observed to go from one side of the tray across the whole tray area to form a puddled brown area on the side of the tray closest to the floor of the closet. Formica missing around sink area, caulking sink and counter area missing or bubbly, bed rails dirty looking with dark substance on bedrails.

The Environmental Team Leader, EI # 2 was interviewed on 7/2/12 at 11:00 AM. EI # 2 stated the rooms were to be cleaned everyday while a patient was in the room and the room was to have "extra deep cleaning" when a patient was discharged from the room. EI # 2 also stated the rooms were cleaned by wiping the walls, bedrails, and all areas of the room. EI # 2 verified the tray in room 860 was not clean and the room had been cleaned after discharge of a patient. She also verified there was a cobweb behind the television on room 867.

Room 821 - Caulking around sink and counter top was bubbly or missing, some baseboards were missing and some baseboards were loose from wall, Bedrails with sticky dark substance, broken Formica on sink area and air conditioner area, splash of substance on wall below light above bed, a sticky brown substance on foot of bed, and bedside table with a brown substance on the front edge.

Observations on 7/2/12 at 11:40 AM
Included:
Room 820 - Missing Formica on front of sink, Caulking missing or bubbled and loose, and dust on television and cords.
Room 819 - Missing Formica sink area and air conditioner area.
Room 818 - Missing Formica sink area and caulking around sink area bubbled.
Room 805 - Missing baseboards, missing Formica on sink counter, a Thermometer was on the dry erase board ledge, build up of a dark substance on bed rails, bed rail with clear tape attached, a brown hair with dust attached with more hairs was observed on the head board.

EI # 1 was asked if this room was clean and EI # 1 verified the room appeared to be cleaned. The surveyor informed EI# 1 an opened Thermometer was on the dry erase board ledge and EI # 1 removed the thermometer.

Observations on 7/2/12 at 12:00 Noon
Included:
Room 801 - The top drawer of the 4 drawer chest in the room was opened and inside was an opened tube of Vitamin A & D ointment and a opened Yankauer Suction instrument. There were various ventilator supplies and a bottle of Artificial Tears ointment 3.5 g (grams) with Medical Record (MR) # 3's name on the label of the medication. MR # 3 had a diagnosis of Acute Respiratory Failure. The "Routine Referral Donor Form" dated 6/29/12 revealed MR # 3 had MRSA (methicillin-resistant Staphylococcus aureus) and was not a candidate for eye donation.

Observations on 7/3/12 at 8:10 AM
Included:
Common Shower area - There continued to be a shirt on the floor and an unopened bar of soap

Room 867 continued with same concerns as 7/2/12.

Observations on 7/3/12 at 8:33 AM
Included:

Room 861 - Caulking around sink area missing, bubbly or pulling away from sink area, broken Formica in sink area. Bedrails with dirt like areas on bedrails. The metal head of bed had 5 different hairs on left side and the right side of the head of the bed had 2 hairs, and dust on television and cords.

Room 860 - continued with same concerns as 7/2/12.

Room 821 - continued with same concerns as 7/2/12.


EI # 3 was interviewed on 7/5/12 at 7:45 AM and EI# 3 verified there were several environmental areas needing additional monitoring and correcting.