HospitalInspections.org

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Based on observation, document review and interview, the hospital failed to ensure staff completed annual training and competency assessment for immediate use-parenteral products utilizing the laminar airflow hood for 2 of 2 registered nurses (Staff #1010 and #1011).

Failure to ensure that nursing staff are competent in skills, techniques, and procedures risks patient safety from inadequate care.

United States Pharmacopeia (USP) - General Chapter 797 - "Sterile Compounding - Sterile Preparation" (Revised April 2016).

Findings included:

1. During a tour of the hospitals Acute Care unit on 08/23/21 at 2:30 PM, Surveyor #10 interviewed a registered nurse (Staff #1015) about compounding sterile intravenous (IV) medications. Staff #1015 stated the licensed nursing staff prepare immediate use IV medications in the laminar flow hood (located in the medication room) just prior to administration. She stated that she had not received any formal initial or annual training by the pharmacy service or from the hospital nursing department in sterile product preparation during her orientation. She was unaware if there was a hospital policy and procedure on preparing IV admixtures.

2. Document review of the hospitals policy titled, " Preparation of Immediate-use Parenteral Products Training,"policy # 40.29, revised date 02/10/21, showed that nursing staff will undergo training and competency assessment annually and initial training utilizing the laminar airflow hood.

3. Record review of the personnel files for two registered nurses (Staff #1010 and #1011) showed annual documentation of education, training, or verification of clinical competency for compounding sterile products for injection for 2019.

4. On 08/25/21 at 12:15 PM, Surveyor #10 interviewed the Chief Nursing Officer (Staff #1012) about annual documentation of education, training, and verification of clinical competency for compounding sterile products for injection. Staff #1012 stated that staff nurses receive on the job training on how to mix and reconstitute intravenous antibiotics using the laminar airflow hood. Staff #1012 confirmed Staff #1010 and #1011 had not received competency training in 2020.

5. On 08/25/21 at 12:00 PM, Surveyor #10 interviewed the Director of the Pharmacy (Staff #1014) about sterile compounding of IV medications. Staff #1014 stated that the nursing staff prepare IV medications for immediate use only when there are no commercial products available. He confirmed the pharmacy service has not provided any training to the nursing staff on preparing sterile IV admixtures. Staff #1014 stated he was involved in developing a training video for nursing staff.
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Item #1 - Processing reusable patient care supplies

Based on observation, interview, and document review, the Critical Access Hospital failed to adequately clean patient care equipment prior to sterilization.

Failure to properly clean patient care equipment risks contamination with microorganisms and places patients at risk for infection.

Resource: Centers for Disease Control and Prevention (CDC) Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, Update May 2019. Factors Affecting the Efficacy of Disinfection and Sterilization: Cleaning, " ... items must be cleaned using water with detergents or enzymatic cleaners before processing. "

Findings included:

1. Document review of the hospital 's policy & procedure titled, " Processing of Reusable Instruments and Devices: High-Level Disinfection and Sterilization of Semi-Critical and Critical Items, " no policy number, no review date, showed that staff are to follow Centers for Disease Control and Prevention (CDC) guidelines. Staff are to clean medical devices as soon as practical after use.

2. On 08/24/21 at 9:50 AM, Surveyor #6 toured Central Sterile services with a Certified Nursing Assistant (CNA) assigned to sterile processing (Staff #602). The observation showed that a bin containing 15-20 hinged instruments ready for processing were dry and did not appear to have been cleaned.

3. At the time of the observation, Surveyor #6 interviewed Staff #602 about sterilization processes. Staff #602 stated that the instruments are collected "over a few days, some of the instruments had been used 4 days ago." Staff #602 stated that the hospital might have had a procedure in the past that included cleaning prior to processing.

Item #2 - Hinged instruments

Based on observation, interview, and document review, the Critical Access Hospital failed to clean, disinfect, sterilize and store patient care equipment according to acceptable standards of practice.

Failure to properly clean, disinfect, sterilize and store patient care equipment risks contamination with microorganisms and places patients at risk for infection.

Resource: Centers for Disease Control and Prevention (CDC) Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, Update May 2019. Factors Affecting the Efficacy of Disinfection and Sterilization: Cleaning, " ... hinged instruments should be opened fully to allow adequate contact with the detergent solution; ... " Sterilizing Practices: Packaging. " ...hinged instruments should be opened; " Loading. " All items to be sterilized should be arranged so all surfaces will be directly exposed to the sterilizing agent. ... allow for free circulation of steam (or another sterilant) around each item. "

Findings included:

1. Document review of the hospital ' s policy & procedure titled, " Processing of Reusable Instruments and Devices: High-Level Disinfection and Sterilization of Semi-Critical and Critical Items, " no policy number, no review date, showed that staff are to follow Centers for Disease Control and Prevention (CDC) guidelines.

2. On 08/23/21 at 3:50 PM, Surveyor #6 observed 2 peel packages of instrumentation with closed hinges in the Central Sterile storage room.

3. At the time of the observation the Chief Nursing Officer (Staff #601) confirmed the finding and referred the surveyor to sterile processing staff.

4. On 08/24/21 at 9:50 AM, Surveyor #6 toured Central Sterile services with a Certified Nursing Assistant (CNA) assigned to sterile processing (Staff #602). The observation showed several peel packages of instrumentation with closed hinges.

5. At the time of the observation, Surveyor #6 interviewed Staff #602 about sterilization processes. Staff #602 stated that she did not know that hinged instruments should be open.

Item #3 - Decontamination room handwashing station

Based on observation and interview, the Critical Access Hospital failed to provide a handwashing station in the Central Sterile Department decontamination room used for decontamination of shared patient care equipment prior to sterilization.

Failure to provide hand-washing stations places staff at increased risk of exposure to infectious microorganisms during reprocessing of contaminated patient care equipment.

Reference: Facilities Guidelines Institute (FGI) Guidelines for Design and Construction of Health Care Facilities, Part 2 - Hospitals; 2.1-2.3.8.1 Soiled workrooms shall contain (1) A clinical sink (or equivalent flushing-rim fixture) and a hand-washing station. Both fixtures shall have a hot and cold mixing faucet.

Findings included:

1. On 08/24/21 at 9:50 AM, Surveyor #6 toured Central Sterile services with a CNA assigned to sterile processing (Staff #602). The observation showed the decontamination room was equipped with 2 stainless steel sinks and a hopper sink along one wall. A paper towel dispenser was mounted between the 2nd stainless steel sink and the hopper.

2. At the time of the observation, Surveyor #6 interviewed Staff #602 about where staff washed their hands. Staff #602 stated that she did not know but any sink could be used for handwashing.

Item #4 - Sterilization room handwashing station

Based on observation and interview, the Critical Access Hospital failed to provide a handwashing station in the Central Sterile Department sterilization room.

Failure to provide hand-washing stations places staff at increased risk of exposure to infectious microorganisms during reprocessing of patient care equipment.

Reference: Facilities Guidelines Institute (FGI) Guidelines for Design and Construction of Health Care Facilities, Part 2 - Hospitals; 2.1-2.3.7.1 Clean workroom. If the room is used for preparing patient care items, it shall contain a work counter, a hand-washing station, and storage facilities for clean and sterile supplies.

Findings included:

1. On 08/24/21 at 9:50 AM, Surveyor #6 toured Central Sterile services with a CNA assigned to sterile processing (Staff #602). The observation showed a handwashing sink blocked by a perforated sheet of stainless steel used for workspace.

2. At the time of the observation, Surveyor #6 interviewed Staff #602 about the blocked handwashing station. Staff #602 stated that the sink worked but the workspace was small.

Item #5 - Disinfectant contact time

Based on observation, document review, and interview, the Critical Access Hospital failed to ensure staff had knowledge of the contact time (time required to effectively reduce the amount of pathogens) for disinfectant chemicals used in patient care areas.

Failure to allow adequate time for disinfection of surfaces places patients and staff at increased risk of exposure to harmful microorganisms.

Reference: Centers for Disease Control and Prevention (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities (2003), updated 07/19: Part II. E. Recommendations - Environmental Surfaces I. Cleaning and Disinfecting Strategies for Environmental Surfaces in Patient-Care Areas A. Select EPA registered disinfectants and use them in accordance with manufacturer's instructions.

Findings included:

1. Document review of the hospital's policy titled, " Emergency Room Turnover Cleaning, " policy number 8460.23, reviewed 10/07/20, showed that staff are to wipe all high touch surfaces with hospital approved wipes and let air dry for a minimum of 4 minutes.

Review of label instruction for PDI Super Sani-Cloth Germicidal Disposable Wipe (a quaternary ammonia based disinfectant) showed that treated surfaces must remain wet for 2 minutes.

Review of label instruction for Alpha-HP (a hydrogen peroxide based disinfectant cleaner) showed that for use as a one-step cleaner/disinfectant all surfaces must remain wet for 10 minutes.

2. On 08/23/21 at 3:00 PM, Surveyor #6 observed an Emergency Room Turnover Cleaning of ER6A/ER6B by a Health Unit Coordinator (Staff #603). The observation showed that Staff #603 used PDI Super Sani-Cloth wipes to disinfect the gurney mattress. Staff #603 began at the head of the mattress and wiped the top and sides down to the foot. The mattress appeared wet at the head but dry at the foot.

3. At the time of the observation, Surveyor #6 asked Staff # 603 about the contact time for the disinfectant he was using. Staff " 603 stated he did not have an answer.

4. On 08/25/21 at 9:15 AM, Surveyor #6 interviewed a Housekeeper (Staff #604) about the procedures for a terminal cleaning of patient rooms, procedure rooms, and emergency rooms. Surveyor #6 asked Staff #604 about the contact time for Alpha-HP, the disinfectant used during terminal cleaning procedures. Staff #604 stated that she did not know the contact time but by the time she is finished, the whole room is dry.

Item 6 - Environmental cleaning procedures

Based on observation, interview, and document review, the Critical Access Hospital failed to ensure staff used effective infection control techniques following patient discharge from the Emergency Department (ED).

Failure to comply with policies and procedures to prevent transmission of infections puts patients and staff at risk from communicable diseases.

THIS IS A REPEAT CITATION - PREVIOUSLY CITED AUGUST 2017

Findings included:

1. Document review of the hospital ' s policy titled, " Emergency Room Turnover Cleaning, "policy number 8460.23, reviewed 10/07/20, showed that staff are to wipe all high touch surfaces, including gurney mattress, top sides, flip and other side, and all counter tops.

2. On 08/23/21 between 3:00 PM and 3:10 PM, Surveyor #6 observed an Emergency Room Turnover Cleaning of ER6A/ER6B by a Health Unit Coordinator (Staff #603). The observation showed:

a. Staff #603 used PDI Super Sani-Cloth wipes to disinfect the gurney mattress top and sides but did not disinfect the underside of the mattress or the support surface of the bed frame.

b. Staff #603 disinfected a clear area of the counter beside the handwash sink. He did not remove or disinfect unused patient care items on the counter: a roll of Coban 3 " self-adherent bandage wrap, 2 disposable irrigation syringes, and a disposable blood pressure cuff.

3. At 3:10 PM, Staff #603 stated the turnover cleaning was complete. Surveyor #6 asked Staff #603 about the patient care items left on the counter. Staff #603 stated that someone would throw them away. The surveyor asked who would throw them away. Staff #603 stated that he would and then discarded the items.
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Based on observation, document review, and interview, the Critical Access Hospital failed to maintain the environment in a sanitary condition, free of dust.

Failure to maintain sanitary conditions that prevent accumulated dust, a possible source of contamination, places patients and staff at increased risk of exposure to allergens and harmful microorganisms.

Reference: Centers for Disease Control and Prevention (CDC) Guidelines for Environmental Infection Control in Health-Care Facilities (2003), updated 07/19: Part 1. E. Environmental Services b. Housekeeping surfaces require regular cleaning and removal of soil and dust. Part II E Recommendations - Environmental Services I. E. Keep housekeeping surfaces visibly clean on a regular basis.

Findings included:

1. Document review of the hospital's policy & procedure titled, " Environmental Cleaning Policies - Cleaning and Low-Level Disinfection, " no policy number, no review date, showed that staff are to keep housekeeping surfaces visibly clean on a regular basis.

2. On 08/24/21 at 9:50 AM, Surveyor #6 toured Central Sterile services with a Certified Nursing Assistant (CNA) assigned to sterile processing (Staff #602). The observation showed a considerable accumulation of fine black powder around a ceiling diffuser. Areas near the ceiling on 2 walls nearest the diffuser showed a shadow-like dark stain.

3. At the time of the observation, Surveyor #6 interviewed Staff #602 about accumulation around the diffuser. Staff #602 stated that she had not noticed the accumulation.
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