HospitalInspections.org

Based on observation, document review and interview, the facility failed to establish a contract with the off-site Central Sterile vendor who sterilizes surgical instruments used in the Operating Suite.

Findings included:

Observations in the facility's Central Sterile Department during a tour on 8/6/19 at 2:00PM identified the following: Contaminated surgical instruments, packed in metal carts, awaiting transport for off-site sterilization.

During interview of Staff A (Central Sterile Program Director) on 8/6/19 at 2:15PM, Staff A revealed the Northwell Health System had built an off-site Centralized Sterilization Plant for all System hospitals and facilities. The facility initiated off-site sterilization for surgical instruments at this Plant in October 2018.

The meeting minutes for the facility's Executive Committee of the Board of Trustees, dated from 10/15/13, revealed the Committee had authorized the Northshore-Long Island Jewish Health System, Inc. (the "Corporation") to execute contractual agreements with a private corporation to complete the joint venture transaction. The Committee had also authorized all further actions in connection with the Central Sterile joint venture.

During interview of Staff A on 8/8/19 at 11:00AM, Staff A stated the facility did not have a current service contract for the off-site Central Sterilization services that were initiated in October 2018.

The facility could not furnish documented evidence of the following: Delineation of responsibilities for the Central Sterile contractor; evaluation of the Central Sterilization services; or the facility oversight provided.

Based on observation, document review and interview, the facility failed to administer IVP (Intravenous Push) [bolus] medications per facility guidelines, in 1 (one) of 5 (five) observations.

This lapse in medication safety may have placed patients at increased safety risk.

Findings include:

The facility's IV Medication General Reference Guide, dated 2/22/19, instructed staff to administer IV Pepcid over a 2 (two) minute timeframe.

The facility's Intravenous Push (bolus) Drug Administration Competency Checklist, last reviewed April 2019, instructed nursing staff to "flush [the] line if necessary using the correct syringe size and amount of normal saline, then inject drug over the recommended interval...Where applicable, verify guidelines using the facility Medication Reference Guide...then flush...line using the adequate amount of sterile normal saline."

During observation of Staff EE (RN/Registered Nurse) on 8/9/19 at 10:55 AM, Staff EE withdrew IV Pepcid [antacid medication] from a medication vial and administered it to Patient #21 in less than one minute.

Per interview of Staff EE at the time of the observation, Staff EE stated she had "pushed the medication over 10 seconds."

This finding was confirmed by Staff G (Director of Quality), Staff H (Senior Administrative Director of Nursing) and Staff JJ (Senior Director of Patient Care Services) at the time of observation.

Based on observation, document review and interview, the facility failed to maintain a sanitary environment to avoid sources and transmission of infections and communicable diseases, as evidenced by:

(A) Pest infestation;
(B) Cross-contamination during OR (Operating Room) cleaning and terminal cleaning of an isolation room;
(C) Inappropriate transport of soiled linen;
(D) Inappropriate transport of a filled suction canister;
(E) Lack of temperature and humidity monitoring;
(F) Lack of hand hygiene
(G) Lack of medication vial disinfection
(H) Lack of needleless cap disinfection

These lapses in infection control practices place patients and staff at increased risk of infection

(See TAG A0749)

Based on observation, document review and interview, the facility failed to:

(A) Maintain a sanitary environment free of pest infestation
(B) Prevent cross-contamination of equipment and supplies during OR (Operating Room) cleaning and Isolation Room Terminal Cleaning (a method used to control the spread of infections where items in the room are disinfected, sanitized, and/or decontaminated)
(C) Minimize infection control risk during transport of soiled linen
(D) Minimize infection control risk during transport of a filled suction canister
(E) Monitor the temperature and humidity of trucks transporting sterilized surgical instruments
(F) Perform hand hygiene (this includes hand washing, antiseptic hand washing or the use of antiseptic hand rub)
(G) Disinfect the rubber diaphragm tops of IV (intravenous) medication vials prior to withdrawing medication, in 4 (four) of 5 (five) observations; and
(H) Disinfect the IV needleless caps prior to access in 1 (one) of 3 (three) observations

These breaches in infection control practices placed patients and staff at increased risk of infection.

Findings pertinent to (A): Maintain a sanitary environment free of pest infestation

Exterminator Reports dated 6/26/19 to 8/5/19 revealed numerous, almost daily, mouse sightings in various patient rooms on the 3rd Floor of the Cohen Children's Medical Center.

Pest Control Reports dated 6/26/19 to 8/5/19 revealed that rodent traps and bait were being placed, and frequently replaced, throughout all areas, including radiator units in patient care rooms, by the Pest Control Vendor.

Per interview of Staff Aa (Director of Environmental Services/Cohen Building) on 8/9/19 at 9:30AM, Staff Aa stated that mice were entering the building from the outside, and that the facility's engineering staff had sealed all holes in all rooms during the last week of July 2019.

The August 2019 "Complaints and Findings" Log, reviewed on 8/9/19, revealed mouse sighting re-occurrences in the following patient rooms: Room 317 and Room 322 on 8/4/19; Room 317 on 8/5/19 and again on 8/7/19.

Per interview of Staff Bb (Director of Environmental Services/LIJ building) on 8/9/19 at 10:00 AM, Staff Bb stated the facility will "continue with the current action plan until the last one is caught."

It was determined that the facility failed to escalate interventions with changes in action plans to combat the re-occurrence of mouse sightings in patient care areas. This failure continues to place patients and staff at increased safety and infection risk.



Findings pertinent to (B): Prevent cross-contamination of equipment and supplies during OR (Operating Room) cleaning and Isolation Room Terminal Cleaning

During observation of the cleaning and disinfecting of OR #3 after surgery was completed on 8/6/19 between 2:45 and 3:30PM, Staff S (Perioperative Assistant) was observed cleaning a Bear Hugger [warming machine used to treat low body temperature] pad that was draped over the contaminated OR table . Staff S wiped both sides of the pad with cleansing wipes, then placed the clean pad onto the contaminated surface of the OR table. Staff S then removed the pad and placed it onto a contaminated machine.

This finding was confirmed by Staff G (Interim Director of Quality) at the time of observation.

The facility policy and procedure (P&P) titled "Daily Operating Room (OR) In-Between Case Cleaning Procedure," last revised 7/17/17, contained the following statement: "Clean and disinfect OR surfaces and equipment: work from clean to dirtier surfaces."

The facility's "Position-Specific Orientation for Environmental Services," [not dated], instructed staff to "never place anything dirty on top of anything clean."


During the observation of the terminal cleaning of Contact Isolation Room #330 in on 8/8/19 at 1:15PM, the following breaches in infection control protocols by Staff #Cc (Environmental Services) were identified:

1) Staff Cc failed to perform high to low dusting. Two TV screens hung on top of the wall in front of the beds were not dusted or wiped down. Staff Cc stated that there was a duster on the cleaning cart, but she was unable to reach the TV screens with it;

2) The window shade was rolled up without being cleaned;

3) The upper part of the window glass was not completely reachable by staff and was not thoroughly cleaned;

4) 2 (two) IV (intravenous) poles hanging from the ceiling were not wiped and disinfected until the surveyors notified the Director of Environmental Services.

5) Staff Cc put on gloves that were removed from a contaminated box of gloves which remained in the isolation room and should have been discarded prior to the terminal cleaning process.

6) Staff Cc touched garbage that was overflowing in the garbage bin then reached into a packet of new bleach wipes with the contaminated gloved hands. This practice was observed 5 (five) times between disinfection of the inner wall, window, side table, a chair and the head wall (by one bed).

7) Staff Cc was observed disposing of used medical supplies (IV tubing and canisters) while disinfecting a side table, then continued to wipe and disinfect the table with contaminated gloves. This practice was observed 2 (two) additional times during the disinfection and cleaning process.

Per interview of Staff Cc at the time of observation, Staff Cc stated that the room had not been stripped, and that it was the responsibility of the Patient Care Associate to remove all used and soiled equipment and supplies, prior to cleaning.

8) Staff Cc also cross-contaminated the mattress pad by cleaning the upper half of the mattress, then folding the cleaned area under the contaminated underside of the mattress and bed frame. This practice caused cross-contamination of the upper surface of the mattress that was already cleaned and disinfected.

9) Staff Cc failed to follow a pattern while wiping down surfaces to ensure that the total surface area of a furniture/object was thoroughly disinfected without being cross-contaminated. Staff Cc held up the pillow with her left hand and wiped the surface with the right hand, without ensuring that the pillow was disinfected on all sides.

10) Dry, unwiped areas on the door surface were observed after Staff Cc had cleaned and wiped the door.

The facility P&P titled, "Environmental Services Management Terminal Cleaning of Isolation/Precaution Rooms," dated 1/8/18 revealed this policy lacked guidance on the appropriate procedure for high to low dusting, and did not provide instruction on the appropriate cleaning/wiping patterns for different surfaces to eliminate the potential for cross-contamination.



Findings pertinent to (C): Minimize infection control risk during transport of soiled linen

The facility policy and procedure (P&P) titled "Linen Management," last approved 6/21/18, contained the following statement: "Soiled linen should be placed in a soiled linen hamper outside the patient's room and then delivered to the laundry daily."

During observations in the facility's 9 (nine) South Unit on 8/6/19 at 10:15 AM, Staff I (Patient Care Assistant) was observed dragging a filled soiled-linen bag along the unit's hallway into the soiled utility room.

This finding was confirmed by Staff H (Senior Administrative Director of Nursing) at the time of observation.

During observations in the facility's 7 (Seven) North Unit on 8/7/19 at 11:45AM, Staff U (RN/Registered Nurse) was observed carrying a bag of contaminated linen against her body, contaminating her uniform, during transport to the soiled utility room.

This finding was confirmed by Staff H at the time of observation.

During interview of Staff C (Administrative Executive Director of Quality) on 8/9/19 at 10:00 AM, Staff C confirmed that although the facility's policy instructs staff to use linen hampers to transport dirty linen, the policy is a system policy, and that the practice of the facility is to transport linen to the soiled utility room without the use of hampers.


Findings pertinent to (D): Minimize infection control risk during transport of a filled suction canister

During observations in the facility's 9 (Nine) South Unit on 8/7/19 at 9:10AM, Staff II (RN/Registered Nurse) was observed holding, without putting on gloves, and transporting a canister filled with bodily fluid, wrapped in a paper towel, from a patient's room to the soiled utility room.

During interview of Staff II at the time of this observation, Staff II stated that she used the paper towel to hold the canister, and no gloves, because she wasn't allowed to wear gloves in the hallways.

This finding was confirmed by Staff H (Senior Administrative Director of Nursing) at the time of observation.

A facility policy for the appropriate removal of contaminated items from patient rooms was requested but was not available.



Findings pertinent to (E): Monitor the temperature and humidity of trucks transporting sterilized surgical instruments

The facility's Electronic Off-Site Instrument Sterilization Records dated from October 2018 to present, revealed no documented evidence of temperature and humidity monitoring of the trucks utilized to transport sterilized instruments in order to ensure sterile package contents do not become moist and contaminated.

During interview of Staff A (Program Director of System Sterile Operations) on 8/8/19 at 10:00 AM, Staff A stated that the trucking company monitored the temperature and humidity on the truck. Staff A was not able to obtain or furnish documented evidence of the temperature and humidity monitoring for the trucks.



Findings pertinent to (F): Perform hand hygiene

The facility policy and procedure (P&P) titled "Hand Hygiene," last approved 7/19/18, contained the following statement: "perform hand hygiene (even when gloves are used): before and after contact with each patient ...after contact with and inanimate object that is potentially contaminated ...before donning gloves and after removing them ...and before administering medication."

During observation of Staff N (RN/Registered Nurse) on 8/6/19 at 12:15PM, while providing direct care to Patient #14, Staff N removed her contaminated gloves and without performing hand hygiene, retrieved new gloves from the glove box and put them on.

This finding was confirmed by Staff G (Interim Director of Quality) at the time of observation.

During observation of Staff R (Perioperative Assistant) on 8/6/19 at 3:05PM, while cleaning OR (Operating Room) #3, Staff R removed her contaminated gloves and, without performing hand hygiene, retrieved new gloves from her pockets then put them on. Staff R was observed on 3 (three) subsequent occasions removing contaminated gloves and putting on clean gloves without performing hand hygiene.

During interview of the Staff R at the time of observation, Staff R confirmed she should have performed hand hygiene in between glove changes.

This observation was confirmed by Staff G at the time of observation.

Observations in the facility's OR #10 during a tour on 8/8/19 between 1:00PM and 1:45PM, identified the following: Staff X (Anesthesiology Resident) was providing anesthesia care to a patient. Staff X removed his contaminated glove from one hand, adjusted the oxygen settings on the anesthesia machine, then without performing hand hygiene, retrieved new gloves and put them on. Staff X repeatedly removed his contaminated glove(s) and put on clean gloves without performing hand hygiene, including during patient intubation and while administering medication, in the presence of Staff W (Anesthesiologist), who had direct oversight of Staff X and failed to correct the breaches in infection control.

This finding was confirmed with Staff HH (Interim Administrative Perioperative Manager) at the time of observation.

The same problem of failing to perform hand hygiene after removing contaminated gloves and before putting on clean gloves was observed with Staff P (Maintenance Worker), Staff Q (RN), Staff T (Anesthesia Technologist), Staff W (Anesthesiologist), Staff Y (Perioperative Assistant) and Staff Z (RN).

During interview of Staff G at the time of these observations, Staff G confirmed that staff members should have performed hand hygiene prior to putting on clean gloves and after removing contaminated gloves.


Findings for (G): Disinfect the rubber diaphragm tops of IV (intravenous) medication vials

The facility policy and procedure (P&P) titled, "Multiple Dose Injectable Medication Vials (MDV's)," last revised March 2019, contained the following statement: "The diaphragm of all MDVs must be cleaned with alcohol swabs and allowed to air dry prior to each needle entry."

The Institute for Safe Practice Medication Practice's "Safe Practice Guidelines for Adult IV Push Medications," dated 2015 stated, "Practitioners may not be aware that the "pop-off" vial caps from manufacturers are considered "dust covers" and are not intended to maintain sterility of the vial diaphragm or access point. Thus, the diaphragm must always be
disinfected after removing the cap of a new vial."

During observation of Staff V (RN) on 8/7/19 at 12:00PM, while administering Insulin to Patient #26, Staff V removed the cap from the Insulin vial and, without cleansing the diaphragm, inserted a needle, withdrew the medication and administered it to the patient.

Per interview of Staff V at the time of the observation, Staff V stated that she didn't cleanse the top of the rubber stopper because it is a new vial of medication and that it was sterile.

This finding was confirmed by Staff H at the time of observation who acknowledged that all medication vials, including new vials, must be cleaned prior to needle entry.

During observation of Staff EE (RN) on 8/9/19 at 10:55 AM, while administering Pepcid to Patient #21, Staff EE removed the plastic cap from the Pepcid vial and, without cleaning the rubber diaphragm, inserted a needle into the vial, withdrew medication and administered it to the patient.

These findings were confirmed by Staff G and Staff H at the time of observation.

The same failure to cleanse the diaphragms of medication vials was found during observations of Staff W (Anesthesiologist) and Staff X (Anesthesia Resident).


Findings for (H): Disinfect the IV needleless caps prior to access

The facility P&P titled "IV Insertion (Short Peripheral Catheters) Adult," last approved 10/20/16, contained the following statement: "Prior to accessing the peripheral IV with a syringe...., the (IV) needless cap must be cleaned with an alcohol prep swab for five (5) seconds and allowed to air dry."

The facility's Intravenous Push (bolus) Drug Administration Competency Checklist, last reviewed April 2019, lacked direction for cleansing the IV needleless caps prior to flushing with normal saline, as per facility policy.

During observation of Staff EE (RN) on 8/9/19 at 10:55 AM, while administering Pepcid to Patient #21, Staff EE failed to cleanse the IV needleless cap with alcohol prior to flushing the line with normal saline.

This finding was confirmed with Staff JJ (Senior Director of Patient Care Services) at the time of observation.

Based on medical record (MR) review, document review and interview, in 1 (one) of 3 (three) MRs reviewed, nursing staff did not ensure patients or their caregivers were educated on the potential risks of a Central Venous Catheter (CVC).

This lapse in patient/family education placed patient at increased safety and infection risk.

Findings included:

Review of Patient #13's MR identified that on 8/2/19, a Peripherally Inserted Central Catheter (PICC) was placed. From 8/2/19 to 8/6/19, four days after insertion, there was no documented evidence the patient, nor the patient's caregiver, had been educated about the potential risks of a PICC line.

This finding was confirmed by Staff M (Registered Nurse) and Staff H (Senior Administrative Director of Nursing) at the time of observation. Staff H confirmed the patient and/or caregiver should have received education regarding the PICC.

The facility policy and procedure (P&P) titled, "Knowledge-Based Charting (KBC)," last approved 10/18/18, contained the following statement: "The RN will document each episode of teaching including the patient and or family's response on the Education/Outcome section of the Plan of Care Flowsheet."