HospitalInspections.org

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Based on observation, interview, and document review, the hospital failed to implement their policy and procedure to have envionmental services clean each patient room at discharge before admitting another patient to the room.

Failure to implement their policy consistently puts patients at risk for infection.

Findings included:

1. Document review of the hospital's policy titled, "Cleaning and Disinfection of the Environment & Equipment Policy," policy #104.85, revised 04/21, showed that environmental services (EVS) was to clean patient rooms after each patient discharge.

2. Observations of the emergency department (ED) on 04/27/22 showed nursing staff cleaning high touch services between patients which included the patient bed and counter tops. The patient rooms were not cleaned throughly between patients to include the patient floors and overhead lights. Several patient care rooms had visable dirt and blood noted on the floor. The hallways of the ED had dirt and blood splattered floors.

3. On 04/27/22 at 9:40 AM, the investigator interviewed a registered nurse (Staff #1). Staff #1 stated that nurses cleaned the high touch surfaces between patient admissions. The cleaning of the patient floors and other surfaces of the patient rooms was to be done by EVS staff at discharge but this did not always occur before another patient was brought to the room. Staff #1 stated that EVS did not have a designated person for the ED. ED staff would have to call EVS staff that was assigned to another patient care unit to come clean the patient room.

4. On 04/28/22 at 10:00 AM, the investigator interviewed a registered nurse (Staff #2). Staff #2 verified the above information. Staff #2 stated that due to the volume of patients seen in the ED having EVS staff assigned to the ED would help ensure the ED was kept clean.


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