HospitalInspections.org

Based on review of documentation, observations, tour, and interview, the facility failed to ensure that all essential mechanical, electrical, and patient-care equipment is maintained in safe operating condition, as evidence by failing to properly store scoped and monitor humidity levels in the Operating Room and Sterile Processing Department.

Findings included:

According to the Centers for Disease Control article "Essential Elements of a Reprocessing Program for Flexible Endoscopes - Recommendations of the HICPAC" found at https://www.cdc.gov/hicpac/recommendations/flexible-endoscope-reprocessing.html stated in part,
"Recommendation

Essential Steps for Flexible Endoscope Reprocessing

To ensure flexible endoscopes are safe for patient use, all staff involved in reprocessing this equipment must understand and consistently follow a number of steps which have been distilled down to seven essential steps. Ensuring adherence to these steps requires a complete and effective reprocessing program. These recommendations apply to all settings where endoscopic procedures are performed and where endoscopes are reprocessed ...

6. Storage
a. After reprocessing is complete, store endoscopes and accessories in a manner that prevents recontamination, protects the equipment from damage, and promotes drying. Store processed flexible endoscopes in a cabinet that is either:
i. of sufficient height, width, and depth to allow flexible endoscopes to hang vertically without coiling and without touching the bottom of the cabinet OR
ii. designed and intended by the manufacturer for horizontal storage of flexible endoscopes."

According to the APIC Association for Professionals in Infection Control and Epidemiology reference, "Guideline Summary: Processing Flexible Endoscopes" found at https://apic.org/Resource_/TinyMceFileManager/Implementation_Guides/10_AORNGuidelineProcessingFlexibleEndoscopes.pdf stated in part,

"IX. Flexible endoscopes and endoscope accessories should be stored in a manner that minimizes contamination and protects the device or item from damage.
Cabinets used for the storage of flexible endoscopes should be situated in a secure location in the clean workroom of the endoscopy processing area in a two-room design or in a separate clean area close to, but not within, the endoscopy procedure room.
o Storage cabinets should have doors and should be located at least 3 ft (0.9 m) from any sink.
Flexible endoscopes should be stored in a drying cabinet.
o If a drying cabinet is not available, flexible endoscopes may be stored in a closed cabinet with HEPA-filtered air that provides positive pressure and allows air circulation around the flexible endoscopes.
Flexible endoscopes that have been mechanically processed should be stored in a cabinet that is either
o designed and intended by the cabinet manufacturer for horizontal storage of flexible endoscopes or
o of sufficient height, width, and depth to allow flexible endoscopes to hang vertically without coiling and without touching the bottom of the cabinet.
Flexible endoscopes should be stored with all valves open, and removable parts should be detached but stored with the endoscope.
Flexible endoscopes should be clearly identifiable, with a distinct visual cue, as processed and ready for use."

During a tour of the Surgical Area on 08/17/22, the surveyor asked to see where the endoscopes were stored. The Director of Surgical Services escorted the surveyor to a closet/small room located near the sterile processing area. 4 endoscopes were observed hanging off hooks in this closet/small room, open to air. The Director of Surgical Services indicated the door to this room remained locked. The Director of Surgical Services was asked if the endoscopes were ever stored in a cabinet. The Directors of Surgical Services replied that "we used to hang them in a cabinet until another group told us not too".

Per professional recommendations cited above, endoscopes should be stored in a cabinet to prevent contamination and damage to the scopes.

According to Association of periOperative Registered Nurses (AORN) statement "Relative Humidity Levels in the Operating Room Joint Communication to Healthcare Delivery Organizations 2015" found at at http://aorn.org/-/media/aorn/guidelines/position-statements/posstat-endorsed-relative-humidity-joint-communicaiton.pdf stated in part,

"o At the request of a number of healthcare delivery organizations (HDOs), ASHRAE (the American Society of Heating, Refrigeration and Air Conditioning Engineers) investigated and revised its international standard for HVAC design parameters in 2010 (Addendum D to the 2008 version). The environmental RH for anesthetizing locations, including operating rooms was changed to expand the minimum end of the range from 30% to 20% RH ...

Certain Technology and Supplies Require Higher Relative Humidity Levels

o Relative humidity can impact the shelf life and product integrity of sterile supplies. Some products, such as biological indicators and chemical indicators used for sterilization monitoring and EKG electrodes used for patient monitoring, are very sensitive to humidity (in fact, EKG electrodes are in foil pouches primarily to protect against changes in external humidity levels). Other consumables for some electrosurgical products also are humidity sensitive."

Facility policy entitled, "Temperature and Humidity in Surgical Services" stated in part,
"PURPOSE:

The temperature and humidity in the Surgical Services Department will be maintained according to the AORN guidelines.

POLICY /SCOPE:
The areas will be monitored on an individual room basis. Temperature/ Humidity monitors will be placed in the following rooms:
o OR 1 ...
Central Sterilization
Sterile Storage ...

1. Humidity
a) The relative humidity in a restricted area should be maintained within a range of 20% to 60%.
b) The humidity in a semi-restricted area is related to the function performed in that area:
* clean/sterile storage - maximum 60%
* soiled workroom/decontamination room- no recommendations
* sterilizer equipment access - no recommendations
* semi-restricted corridor no recommendations ...

3. The monitor's level is recorded in a computer-based website. The readings are printed out at the end of each month and kept in a binder in the Surgical Services office."

Review of the temperature and humidity logs for the Operating Room and Sterile Processing Department revealed the following:
* The Operating Room had elevated humidity noted (over 60%) from May 2022 through July 2022 on the log that is kept by the contracted air condition service that monitors temperature and humidity at a central offsite location for the facility. However, during a tour of the operating room on 08/17/22 it was noted the actual humidity in the room was 50% and appropriate according to the analogy hygrometer with a dial on the wall versus the electronic monitor mounted on the wall which still indicated a higher humidity (over 60%). It did not feel like the humidity was elevated while touring the room, it appeared the electronic sensor may be recording incorrect values.
* The Sterile Processing Department (SPD) had appropriate humidity readings. However, the temperature and humidity log only had values measured until 07/05/22, meaning the temperature and humidity level had not been tracked since 07/05/22. Interview on 08/17/22, staff member #1 indicated that the contracted air conditioning service that was supposed to monitor the temperature and humidity for the facility had not set up the centralized electronic tracking system in the SPD department. On 08/17/22, it was noted the actual humidity in SPD was 50% and appropriate according to the analogy hygrometer with a dial on the wall versus the electronic monitor mounted on the wall which still indicated a higher humidity (over 60%). It did not feel like the humidity was elevated while touring the room, it appeared the electronic sensor may be recording incorrect values.

In interview on 08/17/22, staff member #2 verified that scopes were not being stored in a cabinet per professional standards. Staff member #2 also verified that there were issues with the centralized monitoring of humidity levels of the Operating Room and SPD areas.

Based on surveyor review of the Health Information Management (HIM) Physician Delinquency Report and interview with the HIM director, the facility failed to ensure that all medical record entries were timed, dated, and authenticated, consistent with its policies and procedures.

Findings included:

Yoakum Community Hospital medical staff rules and regulations dated May 2019 reads [in part],

"The attending physician shall be responsible for the preparation of a complete medical record for each patient.
A complete history and physical examination (H&P) for each admission and surgical procedure is to be completed within twenty-four hours of the patient's or prior to a surgical procedure. A full discharge summary should be completed and signed as soon as possible after the patient's discharge. Any physician who has one or more incomplete records thirty days after discharge of patients shall be notified of the fact. The physician shall have thirty days to complete the records, or he/she will automatically suffer suspension of privileges. He/she shall not write orders except on patients already in the hospital, and the admitting office shall be so notified by the administrator. Privileges will be restored when no deficiencies exist."

A review of the facility's HIM Physician Delinquency Administrative letters, dated August 1, 2022, revealed that staff #10 had 210 delinquent patient charts, and staff #22 had 302 delinquent patient charts.

A review of the facility's HIM 2021-2022 fiscal year PIPR [abbreviation per facility documentation] Medical Records report revealed an increase of delinquent medical charts and H&Ps from July 2021 to July 2022, 312 total charts and 47 delinquent H&Ps to 533 delinquent medical charts and 52 delinquent H&Ps

Surveyor review of the August 2022 physician schedule revealed that staff #10 and #22 were scheduled to work multiple days despite delinquencies.

Findings were validated by staff #3 during an in-person interview in the facility's conference room on 8/17/2022. Staff #3 stated, "Yes, only two doctors are responsible for the delinquent charts. I have had many conversations with them personally about the issue. They are trying to get caught up. One doctor sat down and cleared up about 100 charts. We are a rural hospital and are not able to suspend them like the bylaws state because we are limited on practitioners."

Based on review of documentation, interviews, observations, and tour the faciliyt failed to maintain a clean and sanitary environment to avoid sources and transmission of infection.

Finding included:

Facility based policy titled, "Infection Control-Environmental Services" stated in part,
"INFECTION CONTROL PRACTICES:

Sanitation within the hospital environment depends upon cleaning thoroughness and frequency. There shall be procedures for cleaning walls, floors, windows, beds, furniture, draperies, carpets, waste containers, bathrooms, equipment, stairs, special patient care departments and other nonpatient care areas.

Patient Rooms
All upward facing horizontal surfaces should be damp cleaned daily."

Facility contracted kitchen service policy FS3.3 entitled, "STORAGE OF FOOD, SUPPLIES AND EQUIPMENT" stated in part,
"Established guidelines for refrigerated storage: ...
4. All items will be dated and rotated to ensure first in and first out (FIFO).
5. Food items removed from cases will be dated and rotated to ensure first in and first out (FIFO)."

Facility contracted kitchen service policy FS8.10 entitled, "CLEANING AND SANITIZING OF FOOD PREPARATION AREAS" stated in part,
"PROCEDURE: The following procedures have been implemented: ...
4. After cleaning and sanitizing, all food contact surfaces of equipment and utensils will be handled and stored to protect them from contamination."

Facility contracted kitchen service policy FS8.23 entitled, "HANDLING LEFTOVER FOOD PRODUCTS" stated in part,
"Storage:
o All leftovers will be tightly covered.
o All leftovers will be labeled with the name of the item, the date of preparation and the date of disposal.
o Leftovers must be disposed on or before the discard date."

In an article published by Spectrum Health in July, 2014 it was stated "The heavier corrugated cardboard shipping boxes might harbor vermin or insects and spread the pests to areas where the boxes are stored after delivery. Corrugated cardboard boxes are not appropriate as storage units in medical or clean supply rooms. These boxes are not appropriate because they are an excellent harbor for insects and pests."

According to Association for Professionals in Infection Control and Epidemiology (APIC) stated in part, "Supplies must be: Removed from shipping cartons or cardboard boxes before storage to prevent contamination with soil/debris that may be on cartons ...Do not leave outer shipping boxes in clinical areas (due to risk of environmental contamination)." Preventing Infection in Ambulatory Care, Winter 2011/2012; available: http://apic.org/Resource_/TinyMceFileManager/Education/Preventing-Inf-in-Amb-Care-Winter2012-FINAL.PDF

During a tour of the facility on 08/16/22, the following infection control issues were noted:
* Dust was observed on high horizontal surfaces throughout the facility, indicating ineffective cleaning of these surfaces. Dust was noted on high horizontal surfaces in the Emergency Department, including the triage room and throughout the trauma room (including on overhead lamps).
* In the emergency department trauma room, 18 saline syringes and 2 bottles of betadine were noted stored underneath a sink. Items should not be stored under sinks due to the risk of water contamination and potential bacterial growth.
* In the nuclear medicine area 2 external shipping boxes were noted. If corrugated cardboard becomes wet, it becomes a source for bacterial growth. External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of a corrugated material, serve as generators of and reservoirs for dust.
* In the Hyperbaric Wound Treatment area, red duct tape was noted demarking the floor around the hyperbaric chamber, tape cannot be effectively cleaned.
* In the kitchen, chipped floor tiles were noted behind the serving line, preventing effective cleaning of the floor due to the uneven surface.
* A drawer containing utensils such as spatulas and scoops had unidentified crumbs and debris present, indicating ineffective cleaning. A plastic tub containing tongs and other utensils identified by kitchen staff as clean utensils also had unidentified crumbs and debris present.
* Ceiling tiles with water damage were noted in the kitchen above the ice machine and in the Intensive Care Unit biohazard room. The presence of water damage indicated the area could be contaminated with bacterial particles due to the moist environment.
* During a tour of the kitchen on 08/16/22, the following items were noted without a label for contents and when it was prepared: 3 trays of desserts (jello and cake) in the serving line refrigerator and 3 trays of desserts (jello and cake) in the walk-in refrigerator. The kitchen manager stated these desserts were prepared the same day (08/16/22) however no label was in place per facility policy to identify when these items were made, thus it could not be determined if they were fresh or not.
*Two oscillating fans were noted in the food service area. One fan was located on the food counter and the other located on the floor (approximately three feet tall) oscillating between food line workers and the cashier (approximately five feet away). The fans lacked a hazard risk assessment and had visible dust on blades and frame. The CDC recommends avoiding the aerosolization of dust in patient care areas. The buildup and aerosolization of dust can lead to and exacerbation of respiratory illnesses and the development of health care associated infections.
* During a tour of the Surgical Services area on 08/17/22, it was noted in the decontamination area of the sterile processing department, a hole was visible in the ceiling tile around a pipe from the washer to the ceiling. This hole in the ceiling presents\ed a potential entry point for pest, dust, and dirt into this area.
* A tour of the inpatient unit revealed tower fans present in every patient room. The tower fans lacked hazard assessment. Before new equipment is introduced into the facility The Occupational Safety and Health Administration (OSHA) requires a baseline safety industrial hygiene hazard analysis be conducted, the facility documents the risk or hazard analyses, the facility develops a written plan for maintenance and cleaning of equipment, and the infection prevention plan includes a written description of equipment surveillance to minimize infection risk. (https://www.osha.gov/sites/default/files/2.2_SHMS)



The findings were validated on 8/17/22 at 12:25 pm, by staff #2 after tour of the facility. On 8/17/2022 in the facility's conference room, staff #2 stated, "The kitchen staff is contracted. The fans will be coming out of the kitchen. We are going to evaluate whether to keep the tower fans in the patient rooms. I would rather get rid of them."