HospitalInspections.org

Based on observations, review of policies and procedures and interviews with key staff members on November 1-3, 2010, it was determined that the Hospital failed to ensure a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel.

Findings include:

1. During tours of the Hospital Outpatient departments on November 1-3, 2010, it was determined that the Hospital failed to maintain a sanitary hospital environment based on the following observations:
a. A tour of the Sleep Center Department on November 2, 2010 revealed that four (4) of four (4) fans in patient clinical areas had dirty and dusty fan blades.
b. A tour of the Sleep Center Department on November 2, 2010 revealed a grossly moldy shower curtain in the patient shower room.

2. During tours of the Hospital Outpatient Departments on November 1-3, 2010 it was determined that the Hospital failed to ensure the mitigation of risks contributing to healthcare associated infections:
a. A tour of the Surgery & Trauma Specialists Department on November 1, 2010 revealed that in five (5) of five (5) exam rooms, patient linens and gowns were stored uncovered in the immediate area utilized for patient changing and patient exam.
b. A tour of the Sleep Center Department ' s clean patient supplies storage area on November 2, 2010 revealed the storage of a box of patient equipment supplies on the floor and the storage of a dirty fan and a cloth bed cot stored in this clean area.
c. A tour of Pediatrics and Family Medicine Departments on November 2, 2010 revealed that patient care items, i.e.: tongue blades, applicators, were stored in open containers on the counter top below the hand hygiene soap products and paper towels.
d. A tour of the Women ' s Health Care Center Department on November 3, 2010 revealed in two (2) separate procedure exam rooms a total of 3 open containers of NuGauze. An interview with staff revealed this product, when opened, the remaining unused product is used for multiple patients for wound and incision packing.
e. A tour of the Women ' s Health Care Center Department on November 3, 2010 revealed in one (1) procedure room an opened sterile dressing kit (forceps, scissors), placed back into storage on the shelf with sterile dressing supplies.
f. During a tour of the Women ' s Health Care Center Department on November 3, 2010 a clinical staff person was observed, while wearing gloves, walking from the clinical area, through the closed door into the medical records department, where she obtained a patient medical record and then returned to the clinical area.
g. A tour of the Urologic Surgery Department on November 2, 2010 revealed in two (2) procedure patient exam rooms, each contained a large unsecured floor sharps container with large opening. An interview with staff revealed that it was not known if a site specific hazard vulnerability analysis (Occupational Safety & Health Administration: OSHA Standard, National Institute for Occupational Safety and Health's: NIOSH recommendation) was completed to ensure this was a safe practice for patients or staff.
h. A tour of the Pediatrics and Family Medicine Departments on November 2, 2010 revealed in two separate medication rooms a total of two (2) unsecured sharps containers on the counter.
i. A tour of the Family Medicine Department on November 2, 2010 medication room revealed a sharps container was mounted at a height where the opening could not be visualized.