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Based on observation and interview the facility failed to ensure adequate ventilation and pressure relationships in Central Sterile Processing, Sterile Storage, Decontamination and Dirty Linen rooms resulting in potential for harm from potential spread of infections to patients served by the facility. Findings include:

See citations for C 224 and C 226.

Based on observation and interview the facility failed to provide a sanitary environment that was free from dust resulting in the potential for transmission of infectious agents among patients served. Findings include:

On 10/25/2016 at approximately 11:30 AM during a tour of the pharmacy, observed an accumulation of dust on top of the pharmacy shelving units.

On 10/25/2016 at approximately 12:10 PM observed an accumulation of dust on top of the Philips electronic cabinet in X-Ray 2.

On 10/25/2016 at approximately 2:45 PM, observed an accumulation of dust under the bottom wire shelf unit in Central Sterile Rm. There was less than 6 inches of clearance under the bottom shelf which is not enough clearance to facilitate cleaning under it.

These findings were confirmed by the the staff Z at the time of the inspection.

Based on observation and interview the facility failed to ensure adequate ventilation and pressure relationships in Central Sterile Processing, Sterile Storage, Decontamination and Dirty Linen rooms resulting in potential for harm from potential spread of infections to patients served by the facility. Findings include:

On 10/25/2016 at approximately 11:40 AM, observed that the Dirty linen room was under a net positive pressure with respect to adjacent areas.

On 10/25/2016 at approximately 2:30 PM, observed that the Sterile Supply Room across from the OR area entrance did not have any supply air provided so that there was no net positive pressure.

On 10/25/2016 at approximately 3:00 PM, observed that the Central Sterile Room (CSR) did not have a net positive pressure with respect to corridor and the adjacent room being used for decontamination of endoscopes and surgical instruments (Dirty Supply Rm). The Central Sterile Room was not being provided with any outdoor air and was not being provided with properly filtered supply air.

On 10/25/2016 at approximately 3:00 PM, observed that the Dirty Supply Room did not have a net negative pressure relationship to the corridor and the Central Sterile Room. The Dirty Supply Room was not having all of its air exhausted to the outside, but a portion of the air was being recirculated through the rooftop air conditioning unit back into the Dirty Supply Room and also the Central Sterile Room.

These findings were confirmed by staff Z at the time of the observation.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on 10/26/16, the facility does not comply with the applicable provisions of the 2012 Edition of the Life Safety Code.

See the K-tags on the CMS-2567 dated 10/26/16 for Life Safety Code.

K-0018
K-0025
K-0047
K-0051
K-0147

Based on observation and interview the facility failed to ensure a system for controlling infection which could result in an increased risk for healthcare acquired infections amongst patients.

Findings include:

On 10/25/2016 at11:31 AM, observed a clean linen cart in the corridor outside of pharmacy that was not fully covered. There was a sheet on top of the cart which was not fitted or large enough to cover the sides to protect the clean linen from possible contamination.

On 10/25/2016 at 2:30 PM, observed a portable dehumidifier in one corner of the Operating room. This equipment may house standing water which can harbor harmful bacteria that, aided by the built-in fan, can potentially be spread throughout the room.

Staff Z confirmed these findings at the time of the inspection.




27408

Based on observation, interview and record review, the facility failed to ensure staff followed manufacturer's guidelines regarding the use of carbon monoxide (Co 2) monitoring tubing (gas sampling line) and oxygen extension tubing in the post anesthesia care unit (PACU) resulting in the potential to spread infection to surgical patients requiring Co 2 monitoring and/or oxygen while in the PACU. Findings include:

On 10/25/16 at approximately 1030, during initial tour of the PACU, the Co 2 gas sampling line was observed attached to a wall mounted respiratory monitoring system with the distal end of the sampling line hanging downward unattached to additional tubing. The gas sampling line had a bright orange sticker attached to it that read, "Do Not Remove". Also, separate oxygen extension tubing, approximately two feet in length, was observed attached to a separate wall mounted oxygen delivery system with the distal end hanging downward unattached to any additional tubing. This oxygen tubing also had a bright orange sticker attached to it that read, "Do Not Remove".
On 10/25/16 at approximately 1035, during an interview with Staff A, Staff A said the gas sampling line and oxygen extension tubing were labeled "Do Not Remove" because the intent was to use the tubing for multiple patients.
On 10/27/16 at approximately 0920, during an interview with Staff B, Staff B indicated both the gas sampling line and oxygen extension tubing were for one time usage only and should never be used for multiple patients.
On 10/27/16 at approximately 1025, during review of manufacturer guidelines, it was revealed the gas sampling line was labeled for single use only.
On 10/27/16 at approximately 1030, during review of the policy titled "Single Use Devices" with a review date last completed November 2015, it was determined, "...items deemed by the manufacturer to be "non-reusable", "single use", "disposable" or any other wording that indicates that the item is for a one-time use on a single patient..."