HospitalInspections.org

A. Based on observation, document review and interview it was determined that for one (8th Floor Medical - Surgical Unit) of three patient care unit, the Hospital failed to ensure staff adherence to infection prevention and control policies and procedures.

Findings include:

1. On 02/04/19 between 10:15 AM - 12:00 PM, an observational tour of the 8th Floor - Medical- Surgical Unit was conducted. There was one can of pop (soft drink) left open on the Medication Supply Station by the Nurses Station.

2. The Hospital's policy titled, "Transmission Based Precautions" revised date 12/2017 was reviewed. The policy included, "...C. Eating and Drinking is prohibited in all work areas (i.e., nursing stations, charting areas, and where there is a potential for occupational exposure to blood, body fluids (i.e., lab, treatment rooms, work areas, nursing stations, where specimens or patient care equipment is place). Food and drink will not be stored..."

3. On 02/04/2020 at approximately 10:10 AM, the Charge Nurse (E #1) was interviewed. E #1 stated, "No food or drinks must be placed on the medication supply station, as it can spill and mess up the medications in the cart. I am not sure who placed that opened can of pop on the medication supply station."

4. On 02/04/2020 at approximately 1:30 PM, the Nurse Manager of Medical -Surgical Unit (E #7) was interviewed. E #7 stated, "It is totally not acceptable to leave a can of opened pop on the medication supply station. It was inappropriate for them to do it."

B. Based on observation, document review and interview it was determined that, for one (8th Floor - Medical Surgical Unit) of three patient care units toured, the Hospital failed to ensure that the stained ceiling tiles were removed and replaced in adherence to the environmental services infection prevention policy.

Findings include:

1. On 02/04/19 between 10:15 AM - 12:00 PM, an observational tour of the 8th Floor - Medical- Surgical Unit was conducted. There were four ceiling tiles with old dried brown stains of leak at the nurses' station that is located around the patient care rooms.

2. The Hospital's policy titled, "Environmental Services IP [Infection Prevention] Standard" revised date 12/2017 was reviewed. The policy included, "Practice Standards: To outline the policy and practices to be followed to ensure adequate and effective environmental cleaning processes designed to prevent the spread of infection ...Ceilings: Ceiling tiles and walls should be inspected daily for peeling or stains which indicate leak. Moist ceiling tiles or drywall are a source of fungi and must be reported to Facilities for immediate repair or replacement."

3. On 02/05/2020 at approximately 1:45 PM, the Director of Plant Operations (E #6) was interviewed. E #6 stated, "The ceiling tiles should have been removed immediately. We want to follow best practices for environment and patient safety. I am not sure why it is still left on the ceiling."

4. On 02/05/2020 at approximately 2:15 PM, the Director of Quality Management (E #12) was interviewed. E #12 stated, "The ceiling tiles that are stained should have been replaced."