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Based on observation, interviews and record review the facility governing body failed to ensure facility staff and contracted housekeeping services performed were provided in a safe and sanitary manner as patient care areas were not cleaned in accordance with facility policy. Facility had a current census of 19 patients.

Findings:

Policy Review:

Review on 10/10/2018 of the facility's current policy and procedure titled "Cleaning and Disinfection of Equipment, Devices and Supplies", Policy # ICP.08.02, Review Date 4/18 reads in part, Purpose: To ensure that medical equipment is appropriately cleaned and disinfected prior to use to prevent the spread of infection or disease. Policy: A. This policy applies to medical equipment that requires disinfection. E. Medical equipment shall be cleaned when visible dirty, ... Patient care equipment shall be damp dusted with germicidal cleaner daily. F. Medical equipment shall be taken to the Soiled Utility area when the equipment needs to be cleaned and disinfected, and/or after the patient is discharge ... ...to reduce the risk of cross contamination between patients. Environmental services personnel shall be responsible for such cleaning and disinfection of equipment. Clean equipment is then covered with a plastic bag and placed in the clean equipment room for use as needed. G. Environmental Services personnel shall clean and disinfect the base of IV poles while in use, traction equipment between patients, blood pressure machines that are permanently affixed on the walls, scales, wheelchairs, stretchers, soiled linen hampers trashy and linen carts, waste receptacles, backboards and other emergency medical services equipment. Procedure: Equipment and working surfaces: All equipment and environmental and working surfaces shall be cleaned and decontaminated after contact with blood or other potentially infectious materials. Reusable Containers: 1. All bins, pails, cans and similar receptacles intended for reuse which have a reasonable likelihood for becoming contaminated with blood or other potentially infectious material shall be inspected and decontaminated on a regular scheduled basis and cleaned and decontaminated immediately or as soon as feasible upon visible contamination.

Review on 10/10/2018 of the facility's current policy and procedure titled "Crash Carts/Defibrillators", Policy # CL1.11, Revised Date 5/2016 reads in part ..... Policy: Crash arts will be located in designated areas throughout the hospital for quick access. 1. Procedures: A. Daily Crash Cart Inspections 1. Each crash cart will be inspected and tested at least daily to ensure the integrity of its contents and validate that the defibrillator is in working order. B. Crash Cart Restock 1) The house Supervisor is responsible for seeing that the crash cart is restocked.

Review on 10/10/2018 of the facility's current policy and procedure titled "Housekeeping" Policy # ICP0.6.03, Reviewed Date 4/18 reads in part .... Purpose: To keep the hospital clean, organized and clutter free. Cleaning of Patient Care Areas: 3. All equipment taken into the room must be disinfected after the room cleaning has completed. 7. Damp wipe all the walls with approved disinfectant. Cleaning of Ancillary Areas: 4. All ledges and surfaces in the room should be checked daily for need of dusting. Environmental Cleaning 1. Thorough scrubbing/disinfecting shall be done for all environmental surfaces that are being cleaned in-patient areas. 11. Sharps containers are removed from patient rooms by nursing and placed in the dirty utility room. Environmental Services then disposes of the sharps container. 16. There shall be no routine washing of walls, blinds and curtains; however, these shall be washed if visibly soiled.

Review on 10/10/2018 of the facility's current policy and procedure titled, "Management of Regulated Waste", Policy # ICP.06.01 Review Date 4/18 reads in part ...Purpose: All biohazard waste except certain recognizable anatomical remains and/or pathological specimens will be disposed by the Environmental Service Department under the supervision of the Environmental Services. Procedure: A., Definition ...Sharps - (objects or devices having acute ridge corners, edges, or protuberances capable of cutting or piercing) including pipettes, needles, blades, slides and any type of glass. Collection: 3. All used needles and syringes are considered biohazard waste and will be disposed of at point of origin in an appropriate sharps collection contain when ¾ full or deemed necessary. 4. These filled containers will be collected by Environmental Services personnel from designated holding locations in each area.

During a tour and observation of the facility on 10/09/2018 at 10:00 a.m. along with the Chief Nursing Officer (CNO). Employee ID # 51.

Crash cart #2 was observed on the 3rd floor. The cart was observed to have visible dust and debris on the lateral surfaces. Review of the daily check list documented the crash was not completed for October 5th and October 8th, 2018.

Crash Cart #3 was observed on the 2nd floor. The cart was observed to have visible dust and debris on the lateral surfaces. Review of the daily check list documented the crash was not completed for October 5th and October 8th, 2018.

Interview with CNO Employee ID #51 on 10/9/2018 at 10:30 a.m. confirmed the crash carts should be checked daily and stated it was done by the supervising registered and was part of her job duties along with keeping it clean and should of wiped own the surfaces of the cart and equipment to keep it clean. Employee ID #51 stated that when the environmental round was made she would make sure the crash carts were inspected

Interview with the supervisory registered nurse Employee ID #56 10/9/2018 at 10:30 a.m. acknowledged it was the supervisory registered nurse's responsibility to for the crash cart equipment testing, and to fill out the daily log and keep the cart clean. Employee ID #56 stated that she had forgotten and not done the checks and she should have kept the crash cart clean.



Further observation of the facility on 10/9/2018 at 11:00 along with Employee ID #51 the following was observed;

Observation of the 3rd floor ICU clean storage area outside of room #311 observed 3 of 5 Intravenous (IV) poles to have visible dust and debris on the lower base of the IV pole along visible surface rust on the base and wheels of the canister. These 3 non sanitized IV poles were observed stored adjacent to IV poles, and EKG equipment that was covered and clean.

Observation of the 3rd floor medical surgical clean storage area revealed 2 Detecto scales (patient lift scales with patient slings) with visible dust on the base and arms of the scales.

Observation of room 318 which had been terminally cleaned and ready for admission. Reddish brownish droplets on the top and side panel of the attached sharps container and reddish brownish droplets along the back wall where the sharps container was attached to the wall and a layer of visible dust on the light panel attached above bed was observed.

Observation of room 328 which had been terminally cleaned and ready for admission revealed 2 disposables digital thermometers on top of the hand towel dispenser, 2 IV poles with visible dust, debris and surface rust on the base and wheel canisters. In addition, a mounted sharps contain was observed over filled with tubing protruding from

Interview with CNO Employee ID #51 on 10/9/2018 at 11:30 a.m. confirmed the IV poles appeared not to be cleaned and should have been cleaned and covered with clear plastic bag prior to moving them out to be stored along with the clean equipment. Employee ID #51 additionally added the sharps container should have been wiped down and disinfected along with the wall near the sharps container.