Failure to Maintain Separate Soiled and Clean Utility Rooms
Penalty
Summary
The facility failed to comply with the regulation requiring separate soiled and clean workrooms in utility rooms. During an observation, it was noted that the Side One soiled utility room lacked a proper keypad locking mechanism, as a button was missing, and the door was left open approximately two inches. Inside the room, there were red biohazardous waste bags and black waste bags on the floor, a folded mattress on the floor, used oxygen tubing in the sink, and more than thirty vacutainers, along with gastrointestinal, urine, and respiratory collection kits, and blood collection needle sets. This indicates that the facility did not maintain the required separation and organization of soiled and clean materials in the utility room, as stipulated by the regulation.
Plan Of Correction
Facility immediately audited all clean supplies were removed from the soiled utility room. Environmental Services (EVS) deep-cleaned and disinfected the space. Facility evaluated lock on utility room door to ensure function. Currently, lock is functional and door does properly close and lock. Facility conducted a facility-wide audit of all utility rooms to ensure soiled and clean items are separated per requirements. By 4/30/25, all relevant staff (including nursing, maintenance, EVS, therapy, and supply chain) were educated by the Infection Preventionist and DON on: - Environmental separation and cross-contamination risks - Proper storage and handling of clean and soiled supplies - Expectations for utility room use and reporting of noncompliance Facility will install new lock on soiled utility room door. Door closer will be adjusted to ensure positive latching. NHA/designee will perform bi-weekly inspections of all clean and soiled utility rooms for 1 month, then monthly thereafter. Results will be logged and submitted to the QAPI Committee.