Observations:
Based on observation , a review of facility policy and procedures, and interview with staff (EMP), it was determined the facility failed to maintain a clean and sanitary environment.
Findings include:
Observation on November 28, 2023, of OR2, at approximately 10:50 AM, revealed used latex gloves on the operating room floor and an ultrasound machine was unclean.
Further observation on November 28, 2023, revealed a small refrigerator (with freezer) in the facility's dirty/contamination room, with blood-like substances at the bottom of the inside of the refrigerator.
A review on November 28, 2023, of facility policy "Cleaning of Equipment" dated June 19, 2012 revealed, "Contaminated work surfaces shall be decontaminated and disinfected with an appropriate disinfectant at the following times: after completion of procedures, immediately or as soon as feasible when surfaces are overtly contaminated,after any spill of blood or other potentially infectious materials, at the end of the work shift if the surface may have been contaminated since the last cleaning..."
An interview conducted on November 28, 2023, at 10:45 AM with EMP 1 confirmed the above findings.
| | Plan of Correction - To be completed: 02/29/2024
By 1/31/24, the Facility Administrator (Center Manager) will provide staff training/education on updated cleaning requirements, including policy review and demonstration, to all facility staff. The facility's Infection Control Plan will be updated to include new cleaning expectations, use of daily log and monitoring activities. In addition, the contracted Cleaning Services Company will be notified of need for improved cleaning.
No later than 1/31/24, the facility will implement updated cleaning procedures for the procedure rooms and the bio-hazard freezer. An updated cleaning log for procedure rooms will be used daily, assigned staff (medical assistants) will complete cleaning tasks as listed (including ensuring no items on floor and all equipment clean), check off tasks completed and sign off on the log. A second staff person (manager, charge person, senior staff) who will sign-off on the cleaning log will monitor cleaning daily. The Administrator will communicate the requirement that the freezer must be kept clean will be communicated to all center staff (via email) and a log will be used to document that the freezer was checked and cleaned as needed. The Administrator will closely monitor cleaning activities weekly for 2 months, then monthly to ensure ongoing compliance to corrective action. The logs, cleaning and freezer, will be monitored weekly (then monthly) by the Facility Administrator, and quarterly by the Risk and Quality Management Coordinator.
Ongoing management and monitoring of facility cleanliness is the responsibility of the Administrator (Center Manager) with support from the Director of Facilities and Director of Patient Services. Monitoring activities including audit findings will be reported to the facility's Patient Safety Committee (next meeting TBD March) and to the Governing Board as part of the quarterly CRQM report. Final copies of Committee and Board meeting minutes will be available for DOH review no later than 2/29/24.
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