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Based on observation and interview, the facility failed to ensure that staff adhered to proper hand hygiene and/or infection control practice in two clinical settings.

Findings include:

During observation at the hospital's off-site Endoscopy suite on 9/5/12 in the morning, Staff G (RN Endoscopy) was observed in the pre-procedure prep area to pick up a computer mouse that had fallen onto the floor and place it into its holder adjacent to the computer without disinfecting the mouse or their hands, and subsequently Staff G went about the prep area touching other objects, until she was alerted to this issue by Staff D (Director Infection Prevention).


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Based on observation the facility failed to ensure that all staff followed recognized infection control standards of practice while providing care during a medication pass.

During medication observation on September 4, 2012 Staff C (Registered Nurse) donned her gloves while preparing IV medications to administer to one of her patients on the medical-surgical unit. During the administration the nurse made several contacts with the patient after which on two occasions Staff C placed her gloved hand into her pocket to retrieve alcohol wipes. This practice was described to Staff D (Director Infection Prevention) who stated that the observed practice was not in keeping with the standards of infection control that are followed at the facility.

Based on observation and interview, it was determined that the facility did not have an adequate system in place for controlling infections and communicable disease, due to mislabeling of a multi-dose medication vial, presence of the multi-dose vial in the patient's immediate prep care area, and lack of proper hand hygiene and environmental hygiene, as observed at one patient's room in the main hospital and/or at the off-site Endoscopy suite (Patient identifiers are #1 and #2). Also, based on observation it was found that the horizontal surfaces in 2 of the 4 operating rooms failed to be cleaned; based on tour of the surgical suites and review of the balance reports for the surgical suite the facility has failed to maintain the proper air changes from the original design; based on interview and record review the facility has failed to have current balance reports to maintain proper pressurization with their procedure rooms; and based on review of the facility documentation and monthly testing reports the facility has failed to maintain the proper negative pressure between the infection isolation rooms and the adjacent spaces.

Findings include:

Observation on 9/4/12 of the second floor hospital inpatient ward revealed Staff E (Charge Nurse), who had gowned and gloved, attending to Patient #1 alone in their room; Patient #1 was on contact precautions for C.diff. (Clostridium difficile) (per observation of signage at the room's entrance and interview with touring facility staff). Upon leaving the room, the Staff E removed gloves and gown, including use of a hand rub, then walked down the hallway from the patient's room to the nurses station where the sink was available for handwashing with soap and water. Staff E failed to do proper hygiene for C.diff. (soap and water) prior to exiting the patient's room.

Observation at the hospital's off-site Endoscopy suite on 9/5/12 in the morning revealed in Procedure Room 3 that a floor pedal control which was positioned off the floor on top of a rectangular piece of electronic equipment. There was no barrier placed between this foot control and this equipment.

Observation at the hospital's off-site Endoscopy suite on 9/5/12 in the morning revealed Patient #2 in a small individual pre-procedure prep area, when Staff F (Charge Nurse) drew up lidocaine from a multi-dose vial that was obtained from a cart just inside this same individualized prep area, and subsequently injected the lidocaine into Patient #2's upper extremity with the syringe. The cart the lidocaine vial was on was in the immediate pre-procedure treatment area for this patient, and observation of the vial shortly after its utilization revealed that it had two conflicting expiration dates marked on it, 9/23 and 9/28. When alerted to this issue by Staff D (Director Infection Prevention), Staff F was observed to replace with lidocaine vial with a new vial.

Observation at the hospital's off-site Endoscopy suite on 9/5/12 in the morning revealed that at the end of the endoscopy procedure performed on Patient #2, in a different Procedure room than above, staff were discarding disposable PPE (personal protective equipment) into a garbage bin in the room which had a spring-type lid which one would push back to access the garbage bin then it would spread back into the closed position. However, as PPE was discarded into the bin, the PPE overflowed blocking the lid from closing completely and inviting staff to discard PPE to into the bin by pushing their PPE against the already discarded PPE that was protruding from the bin.



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"AORN (Association of periOperative Registered Nurses) 2009 Edition Page 439. Recommended Practices for Environmental Cleaning in the Perioperative Setting. Recommendation 1 The patient should be provided a clean, safe environment.

1.b All horizontal surfaces in the OR (eg, furniture, surgical lights, booms, equipment should be damp dusted before the first scheduled surgical procedure of the day. Plasma and monitor screens should be cleaned according to manufactures' instructions.

Dust is known to contain human skin and hair, fabric fibers, pollens, mold, fungi, insect parts, glove powder, and paper fibers among other things. Airborne particles range in size form 0.001 microns to several hundred microns. Contamination for particles can come from an external source (eg, ventilation, doors) or an internal source..."


Based on observation with Staff A (Clinical Coordinator of Surgical Services) it was found that the horizontal surfaces had failed to be cleaned.

Findings include:

During tour on 9/4/12 of the surgical suite it was observed by surveyor and shown to Staff A that 2 of the 4 operating rooms horizontal surfaces had build up of dust on multiple pieces of equipment on their horizontal surfaces.

ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Standard 170-2008 Ventilation of Health Care Facilities

Page 11 #8. Planning, construction, and system startup.

8.1 Overview. For HVAC systems serving surgery and critical care spaces, compliance with this standard requires preparation of an acceptance testing plan.

8.5 documentation of New or Remodeled HVAC Systems. Owners shall retain an acceptance testing report for their files. In addition, the design shall include requirements for operations and maintenance staff training that is sufficient for the staff to keep all HVAC equipment in a condition that will maintain the original design intent for ventilation. Training of operating staff shall include a explanation of the design intent. The training materials shall include, at a minimum, the following:

a. O&M procedures
b. Temperature and pressure control operation in all modes
c. Acceptable tolerances for system temperature and pressures
d. Procedures for operations under emergency power or other abnormal conditions that have been considered in the facility design.

Based on tour of the surgical suites and review of the balance reports for the surgical suite the facility has failed to maintain the proper air changes from the original design.

Findings include:

During tour of the surgical suites on 9/4/12 it was noted and shown to Staff A (Clinical Coordinator of Surgical Services) that the air returns in three of the four operation rooms were very poor. The fourth operating room could not be tested due to a surgical case being performed. A paper test was performed by holding a paper in front of the return were the paper would be pulled in. When this was done the paper would fall to the floor and not be drawn in toward the return showing very little air movement

On review of the facility's airflow report dated 1/18/12 which is the most current balance report it shows as follows:


Supply Air
OR #1 Design Actual
10 150 139
11 175 134
12 175 157
13 175 145
14 175 224
15 175 162
16 175 215
17 175 205
Total 1375 1381

18 159 20
19 175 156
20 175 168
21 175 224
22 175 203
23 175 126
24 175 281
25 175 216
Total 1375 1394

Return Air
Design Actual

26 1125 793
27 1125 964

Supply Air
OR #2 Design Actual

45 175 130
46 175 170
47 175 246
48 175 253
49 175 58
50 175 66
51 175 218
52 175 197
53 175 177
54 175 153
55 175 167
56 175 162
Total 2100 1997

Return Air
Design Actual
57 950 877
58 950 265

Supply Air
OR #3 Design Actual

65 100 89
66 180 197
67 180 188
68 180 179
69 180 186
70 180 177
71 180 154
72 180 188
73 180 206
74 180 200
75 180 175
Total 1900 1939

Return Air
Design Actual
76 800 403
77 800 688

Supply Air
OR #4 Design Actual

84 180 182
85 180 167
86 180 171
87 180 204
88 Not Used
89 180 162
90 180 197
91 180 196
92 180 131
93 180 189
94 180 200
Total 1800 1799
Return Air
Design Actual
95 800 213
96 800 942

All numbers above represent the as built design. The first number is the diffuser or vent, the second number is the design as built number and the third number is the actual air volume at the time the system was balanced, during the time of the balance report.

ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Standard 170-2008 Ventilation of Health Care Facilities

A1. O&M IN HEALTH CARE FACILITIES
A1.1 Operating Rooms. Each operating room should be tested for positive pressure semi-annually or on a effective preventative maintenance schedule. When HEPA filters are present within the diffuser of operating rooms, the filter should be replaced based on pressure drop.

Based on interview and record review the facility has failed to have current balance reports to maintain proper pressurization with their procedure rooms.

Findings include:

During review of maintenance records and Interview with Staff B (Director of Plant Operations) on 9/5/12 it was also confirmed that the facility has not had the HVAC system balance for the endoscope procedure room since January 1, 2007.


ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers) Standard 170-2008 Ventilation of Health Care Facilities. 7.2 Additional Room Specific Requirements.
7.2.1 Airborne Infection Isolation (AII) Rooms. Ventilation for AII rooms shall meet the following requirements whenever an infectious patient occupies the room:

(a) Each AII room shall comply with requirements of Tables 6-1, 6-2, and 7-1. AII rooms shall have a permanently installed device and /or mechanism to constantly monitor the differential air pressure between the room and adjacent spaces of the room when occupied by patients with an airborne infectious disease. A local visual means shall be provided to indicate whenever negative differential pressure is not maintained....

(f) Differential pressure between AII rooms and adjacent spaces that have a different function shall be a minimum of -0.01. wc (-2.5 Pa).

Based on review of the facility documentation and monthly testing reports the facility has failed to maintain the proper negative pressure between the infection isolation rooms and the adjacent spaces.

Findings include:

Review of the facility's maintenance logs on pressurization readings shows all five isolation rooms having a alarm setting at (-0.0039 wc) which is below the minimum standard. When tested by the facility on 8/30/12 which was provided by Staff B (Maintenance Director) the following areas pressurization readings are as follows:

1) ED-c tested (-0.0239 wc) within range
2) 213 tested (-o.0095 wc) out of range
3) ICU 5 tested (-0.0048 wc) out of range
4) 327 tested (-0.0090 wc) out of range
5) IMCU 4 (-0.0082 wc) out of range

Also the facility was unable to provide air balance reports to show that the negative pressure rooms were negative 12 ACH (Air Changes per Hour)