Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 670031 (X3) Date Survey Completed 01/12/2012
Name of Provider or Supplier St Luke's Patients Medical Center Street Address, City, State 4600 East Sam Houston Parkway South, Pasadena, TX
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
A0701 MAINTENANCE OF PHYSICAL PLANT
CFR(s): 482.41(a)

The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured.


This STANDARD is not met as evidenced by:
Based on observation, interview and record review, the Hospital failed to maintain a clean environment. Heavy dust / lint was observed in the emergency room, cardiac Cath lab, and the surgical suite area. Findings include: Initial tour 1/10/12 at 9:40 a.m. revealed heavy dust / lint build up (1/8 inch) as follows: Emergency Room: -ER treatment room #1 had heavy dust / lint build-up on two over-head lights used for suturing. Cardiac Cath Lab: -Treatment room #9 had heavy dust / lint build-up on top of the wall mounted cardiac monitor, the wall mounted TV, and the bottom of the stretcher. -Cath Lab room had heavy dust / lint build up on top of a surgical light, bottom of two IV poles, top of the wall mounted x-ray viewing box, the arms of the Ergo-light, the base of the x-ray C-arm, and the Cath lab patient table. Surgical Suite Area: -Operating room soiled utility room had heavy dust / lint build-up on the ceiling ventilation vent -Medication room had heavy dust / lint build-up on top of the Pyxis medication machine and on top of a refrigerator -Janitor closet had heavy dust / lint build-up on the ceiling ventilation vent -Operating room sub-sterile areas A, B, and C had heavy dust / lint build-up on top of the blanket warmers -Pre-operative holding area room #'s 1, 2, 3, and 4 had heavy dust / lint build-up of top of the wall mounted cardiac monitors, bottom of the stretchers, and on top of a supply cart -Endoscopy Room #3 used for eye procedures had heavy dust / lint build-up on top of two overhead surgical lights and on top of a surgical cabinet. -Endoscopy storage cabinet for scopes had heavy dust / lint build up on top of the cabinet -Recover room had a stretcher that was used of "eye" patients that had heavy dust / lint build-up on the bottom of the stretcher -Step down recovery unit had heavy dust / lint build-up on top of the wall mounted cardiac monitors in room #'s 11, 12, 13, 14, 15, 16, 17, 18, and 19. Also the bottom of the stretchers had heavy dust / lint build-up. During an interview on 01/10/2012 with the the operating room nurse manager (ID# 25Y) she acknowledged that the nursing staff is responsible for cleaning the Cath lab, the surgical suite area, and the recovery room. Record review of a policy titled "Cleaning of Non-Critical Portable Patient Care Equipment" dated 11/2011 stated "Purpose: Reusable non-cortical portable patient care equipment have the potential of becoming contaminated with microorganisms. Proper cleaning and decontamination of the equipment reduces the risk of transmission of pathogens between patient. Procedures: Thoroughly wipe down equipment with a clean cloth saturated with approved cleaning solution..." 17028 Room # 106 During observation rounds on the unit on 1/10/12 at 10:15 am A patient reported that when she was taken to her room on the evening of 1/9/12 the bed was made up but there were spots of blood on the side rail and on the bar at the base of the bed (orthopedic bed). The patient stated her sister cleaned it off and reported to a staff that came in and cleaned the area. Observation on the afternoon of 1/10/12 at 2:15 pm on the surgical unit reveal the following information: Room # 106 was cleaned following a patient discharge. Inspection of the room revealed the floor was cleaned and the bed in the room was made. Further observation in the room revealed there was dust particles on the base of the bed, on the rail beneath the mattress, and in the crevasses. There was visible dust on the bed supports , and a brown looking splatter at the base of a side rail. Staff # 30 D that was present at the inspection stated a patient was discharged from the room about two hours prior and the room was cleaned and ready for a new patient. The Staff had removed the sheets and rolled back the mattress for the inspection. During an interview on 1/10/12 at 2:35 pm with Staff # 31 E, (house keeping staff that cleaned the room) she stated all areas in the room should be dusted and wet wiped with a sanitizer after a patient is discharged from the room. She inspected the room and stated the room would be re- cleaned. Review of the facility's policy/procedure for cleaning patient rooms revealed the following information: 'Dust all ledges, blinds, overhead lights, vents and doors. Disinfect bed rails, frame, mattress, headboard, footboard and under frame."