Volume 2024 | No. 2
SURVEYOR
CRITICAL ACCESS HOSPITAL
Tips for complianc e:
Tips for complianc e:
n During the department interview and review of the EOP, there was no reference to how the organization would collaborate with other state or local emergency management officials or determine how and when to invoke an 1135 waiver. Most policies require review and approval at least every two years. Rarely used policies are equally subject to this timeline as circumstances may change that impact their effectiveness.
Emphasize the link between environmental cleanliness and infection prevention in training for environmental services/housekeeping staff.
n Create infection control quality goals related to a sanitary environment for departments with deficiencies. n Ensure infection preventionists participate in active surveillance rounding to observe for sanitary conditions throughout the hospital. n Encourage all staff to observe for and report a dirty environment and call for cleaning. Include observation for damage to surfaces (floors, walls, doors) and rust on equipment and train on a process for what to do when it is observed.
CHAPTER 18: INFECTION PREVENTION & CONTROL AND ANTIBIOTIC STEWARDSHIP 18.02.01 Risk mitigation measures for infection prevention Overview of the requirement: The hospital has documented policies and procedures addressing management of infection risks through maintenance of a sanitary environment and mitigation strategies to minimize person-to-person transmission of infectious disease. Comment on deficiencies: This broad standard is assessed through observation, response to interviews, and document review. Most deficiencies were observable issues of cleanliness, and the high frequency is a result of the standard covering all areas of the hospital.
18.05.04 Maintenance of ceilings Overview of the requirement:
Ceiling tiles are intact, undamaged, and properly seated to minimize the risk of contaminants falling from overhead spaces into food service or patient care areas. This standard is assessed through observation, Most deficiencies were observable issues of cleanliness, and the high frequency is a result of the standard covering all areas of the hospital.
Comment on deficiencies:
Frequency of citation:
31%
Examples of surveyor findings:
n In the emergency department hallway, eight ceiling tiles were frayed or raised. n Stained ceiling tiles were observed in the infusion center. n There was no policy for maintenance of ceilings and multiple tiles were stained or otherwise damaged. n Add observation of ceilings to expectations for environmental rounding. n Ensure that damaged tiles are immediately replaced.
Frequency of citation:
92%
Examples of surveyor findings:
n Deep divots, large floor seam separations, and OR table rust were observed in two ORs. n In the sterile processing department, in general minor surgical trays, 25 of 41 instruments were noted to have surgical tape that was chipped or broken off. n The lower supply shelves in the ER storeroom had significant dust build up underneath. Several supplies had fallen on the floor and under the storage racks. n The telemetry cardiology cart was very dirty with a thick buildup of dust and debris covering the unit. n The patient nutrition room refrigerator and freezer were extremely dirty with evidence of dried spills on the shelving inside. The rubber seals of the refrigerator and freezer had a thick buildup of dirt, grime, and debris within the folds and along the tops and sides of the seals. n Two bins located in the nurse’s station contained various equipment such as pulse oximeters, thermometers, cords, disposable stethoscopes that had no indication of being clean. The bins themselves were dirty with old adhesive and accumulation of debris and dirt inside.
Tips for complianc e:
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