HospitalInspections.org

Based on Observation and interview, the facility failed to provide a sanitary environment to avoid sources and transmissions of infections and communicable diseases as evidenced by:

-the facility allowing 6 out of 17 patient rooms to have unsafe doors that
could harbor pathogens;
-the facility not completing 2 of 2 temperature logs that stored patient food
and lab specimens, and;
-allowing patient use supplies to be available in unsecured packaging.

Findings included:

TX00336442
TX00309580

Facility policy titled "Storage of Medical Equipment, Devises and Supplies", policy # ICP.08.01, stated that all supplies and medical equipment will be stored in a sanitary manner.

Observation on 3/11/20 at 11:30am of the Medical-Surgical unit of the third floor revealed the following; 6 of the 17 patient room doors, which appeared to made of laminated 'layers', had several portions of their layers missing near the hinge areas (Room #'s 304, 306, 307, 308, 309 & 311). The doors, on average, had approximately 2 feet in length x 3-6 inches of layers of door missing/chipped-off. Average depth was 2-6 millimeters. This allowed a potential area for pathogens to grow, as it was not possible to properly clean, and/or disinfect the doors.

In an interview on 3/11/20 at 11:35am at the time of findings with DQ/Infection Preventionist-Staff#2, he confirmed the doors were an infection-control issue and should have been fixed or replaced.

Observation on 3/11/20 at 11:45am of unoccupied patient room #320 revealed an opened/unwrapped unsecured saline flush syringe, present on the patient's sink, next to toothbrushes and toothpaste.

In an interview with QD/Infection Preventionist-Staff# 2, he stated that the syringe should have been wrapped securely in the sealed plastic bag from the manufacturer.

Observation on 3/11/20 at 12:00pm of patient nourishment refrigerator on the Medical-Surgical unit, which contained perishable snacks, showed that the temperature had not been checked or logged for three different days; 3/6/20, 3/7/20 and 3/8/20.

In an interview with QD/Infection Control Preventionist Staff#2, he stated that the temperature logs should have been completed.

Observation on 3/11/20 at 12:45pm of facility's ICU showed a refrigerator at the nurse's station used for storing patient lab specimens. The temperature had not been checked or logged since 1/29/20.

In an interview on 3/11/20 at 12:45pm at the time of findings, CNO-Staff#3 stated that the temperature log should have been completed.