Initial Comments:
This report is the result of an unannounced onsite complaint investigation (CHL24C187S) completed on March 6, 2024, at Regional Hospital Of Scranton. It was determined that the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Hospitals, 28 PA Code, Part IV, Subparts A and B, November 1987, as amended June 1998.
Plan of Correction:
147.2 LICENSURE
MAINTENANCE OF SAFETY & SANITATION
Name - Component - 00
147.2 Maintenance of safety and
sanitation
The hospital shall be equipped,
operated, and maintained so as to
sustain its safe and sanitary
characteristics and to minimize all
health hazards in the hospital, for
the protection of both patients and
employes.
Observations:
Based on review of facility documents, staff interview (EMP), and observation tour, it was determined the facility failed to ensure a safe and sanitary environment.
Findings include:
Review on March 6, 2024, of facility, "Use of Soiled Linen Cart Policy," published March 14, 2023, revealed "Soiled linen bags / carts are available for the disposal of soiled linen. All soiled linen is considered contaminated and treated as such at the laundering facility. Procedure: 1. Soiled linen will be disposed of in blue bags designated for soiled linen. These bags are located in each patient's room. Soiled linen is not disposable; therefore it is not placed in the red bag waster [sic] container. 2. Filled soiled linen bags will then be disposed of in the laundry cart located in the soiled utility room. Bags should be closed properly and never be over-filled. 3. Soiled linen bags will then be picked up by the Laundry Department. ...."
Review on March 6, 2024, of facility policy, "Police Cleaning," revision/review date December 2021, revealed "Purpose: to detail the correct steps for police cleaning restrooms and public areas in order to maintain a clean and safe environment for patients, visitors, and staff members. ...Procedure: Police cleaning is an inspection and light cleaning of public areas and restrooms that is completed several times during the day. Public Area/Waiting Room Policing: Check the entire area and remove all trash, debris, coffee cups, and torn or used reading material. Empty and re-line all trash receptacles. ..."
Request was made to the facility for a policy related to a safe and sanitary environment. None was provided.
Observation tour of the first floor main hallway in the hospital was completed on March 6, 2024, at approximately 9:10 AM. An open clear plastic bag with multiple food wrappers was noted lying on the floor outside of an office.
Interview on March 6, 2024,with EMP1, at approximately 9:10 AM, confirmed the above findings.
Observation tour of the Intensive Care Unit (ICU) soiled utility room was completed on March 6, 2024, at approximately 9:30 AM. Three (3) green soiled linen bags were tied closed and noted to be on the floor next to the laundry cart. The garbage cart that holds all garbage bags to be removed from the unit was overflowing. Seven tied garbage bags were noted to be stacked on top of a red bag container and a garbage container.
Interview on March 6, 2024, with EMP1, at approximately 9:35 AM confirmed the above findings.
Plan of Correction:The Director of Environmental Services is ultimately responsible for continuous compliance.
The Regional Hospital policy, "Use of Soiled Linen Cart Policy," published March 14, 2023, was reviewed on March 14, 2024 by the Market Director of EVS, Market Director of Facilities, Market Director of Quality, Manager of Clinical Education, Manager of Quality, Chief Nursing Officer, Clinical Lead ICU, and Quality Management Specialist with a revision pertaining to changing the color of the bags from blue to green.
The Regional Hospital policy, "Police Cleaning," revision/review date December 2021, was reviewed on March 14, 2024 by the Market Director of EVS, Market Director of Facilities, Market Director of Quality, Manager of Clinical Education, Manager of Quality, Chief Nursing Officer, Clinical Lead ICU, and Quality Management Specialist with no revisions.
Environmental Services is adding another garbage pickup in the Intensive Care Unit at approximately 10 pm daily to avoid excessive garbage in the soiled utility room.
The Environmental Services staff will be reeducated to both policies in their entirety via an Advanced Learning Center Module. This education is to be completed by April 12, 2024.
The ICU staff will be reeducated to both policies in their entirety via an Advanced Learning Center Module. There will be a specific focus on:
Soiled Linen Cart Policy:
2. Filled soiled linen bags will then be disposed of in the laundry cart located in the soiled utility room. Bags should be closed properly and never be over-filled.
This topic has also been talked about in the daily safety huddle the week of March 11, 2024.
This education is to be completed by April 12, 2024.
The Financial office staff will be educated via face to face education by the manager regarding placing trash in appropriate receptacles, to be completed by April 12, 2024.
An audit of the soiled utility room in the Intensive Care Unit for linen bags and garbage bags outside of the appropriate receptacle will be conducted daily, at random times, by a charge nurse or designee. This monitor will continue until 90% compliance is achieved for 3 consecutive months. Noncompliance will follow the Human Resources process.
The first floor main hallway will be monitored for trash daily on the second shift by the housekeeping supervisor or designee. This monitor will continue until 90% compliance is achieved for 3 consecutive months. Noncompliance will follow the Human Resources process.
The results of these monitors will be presented to the Environment of Care Committee, Quality Committee, Medical Executive Committee, and Board of Directors.
|