HospitalInspections.org

Based on review of documentation and interview, the facility failed to ensure that the condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy.

Findings included:

Facility policy entitled, "RESTRAINT AND SECLUSION, PATIENT MANAGEMENT" stated in part,
"S. STAFF COMPETENCY AND TRAINING ON THE USE OF RESTRAINT AND
SECLUSION
1. All staff having direct patient care responsibilities, including contract or
agency personnel, must demonstrate the competencies specified in this
policy prior to participating in the application of restraints, implementation
of seclusion, monitoring, assessment, or care of a patient in restraint or
seclusion.
2. Training should be targeted to the specific needs of the patient populations
being served, and to the competency level of staff. Training and
competence must be established:
a. Upon hire as part of the initial orientation process
b. Before participating in the use of restraint and seclusion
c. On an annual basis thereafter"

Review of nursing personnel files revealed that 3 of 5 nurses (#13,14, and 15) had "ST. MARK'S MEDICAL CENTER
CARE AND MANAGEMENT OF A PATIENT IN RESTRAINT OR SECLUSION VALIDATION OF STAFF TRAINING AND COMPETENCY" forms in their files, however the the validation of the competency "met" or "not met" was blank. The form was only signed and dated. With this form incomplete it is unknown if these employees wer effectively trained and able to demonstrate competency in restraint application per policy and regulatory requirements.

The above findings were verified with staff members #2 and 29 on 07/28/21.

Based on observation and interview, it was determined that the facility failed to provide a safe and sanitary environment for its staff and patients.

Findings included:

Facility policy entitled, "PATIENT ROOMS" stated in part,
"B. Weekly Cleaning of the Lobbies and Visitors' area:
1. Wear gloves and personal protection equipment.
2. Damp dust all high areas with hospital-approved cleaner disinfectant."

Facility policy entitled, "SURGERY OPERATING ROOMS" stated in part,
"E. At the end of a surgical procedure, the furniture, equipment and floors are cleaned with a germicidal cleaner disinfectant solution...

A. General Information:
1. Surgical team assigned to the OR suite damp dust all furniture, surgical lights and furniture. It has been shown that 90-99% of viable microbes is deposited on the horizontal surfaces in the OR.
2. Damp dusting is completed with a clean, lint-free cloth moistened with germicidal solution (1 oz chemical to 1 gallon water).
3. Surgical team visually inspects the OR suite for cleanliness and verifies that all equipment and furniture are in working order. All
personnel share responsibility in maintaining a clean and safe environment...

C. At the Conclusion of Operative Procedures:...

9. Overhead spotlights are cleaned with a disinfectant on a lint-free cloth. This keeps lamps from being scratched.
10. Sanitation in the OR is essential to remove organic debris and dust.

F. Additional Cleaning Schedule:...

4. Sterile storage area will be mopped and damp dusted every night."

During a tour of the facility on 07/26/21 the following observation were made:
* In patient rooms #106 and 107 dust was observed on high horizontal surfaces, indicating ineffective cleaning.
* Laminate was chipped and peeling throughout the facility, which prevent effective cleaning of these surfaces.
* In the fast track "clean area" the linen cart was observed uncovered with visible dust present on top of the ice machine.
* Several ceiling tiles throughout the fancily had water damage spots visible. The presence of water damage indicated possible contamination from the moisture and airborne bacterial particles.
* In the nuclear medicine area, tape residue was visible on the examination table, preventing thorough disinfection.

During a tour of the facility on 07/27/21 the following observations were made:
* In the operating rooms dust was visible on high horizontal areas, such as the overhead lights in OR #1, indicating ineffective cleaning.
* Tape residue was visible on the operating room stretchers, preventing thorough disinfection. In OR #2 the stretcher mattress had a 3 inch long tears in the side seams preventing thorough disinfection and could allow for the penetration of fluids.
* In the sterilization area/central supply for the surgical area, two autoclaves wer observed with gaps approximately 1 inch in size between the edge of the machine and the wall, preventing a seal around the machine to keep any contaminates from the back of the machine and mechanical elements from entering the clean area, presenting a risk for cross contamination.
* In the endoscope storage room, it was observed the roll down cabinet wer open to air. The Director of Surgical Services verified these cabinets are left open to air. In this room dust was visible on the cabinet across from the scope cabinet, presenting a risk of contamination to the cleaned scopes.
* In the clean equipment storage room, red tape was observed marking area of the floor, tape cannot effectively be cleaned.

The above findings were verified with staff members #2 and 29 on 07/28/21.

Based on a review of documentation and interview the facility failed to ensure that policies governing surgical care must be designed to assure the achievement and maintenance of high standards of medical practice and patient care were enforced, as evidence by failing to ensure biological indicators tests were completed on one load per day per policy.

Findings included:

Facility policy entitled, "Autoclave; Biological Monitoring" stated in part,
"A. Biological monitoring is designed to test sterilizers to ensure proper functions.
B. Biological monitoring is done on all autoclaves daily. This testing is done by using a biological test pack for the steam sterilizers. This system uses Bacillus Stearothermophilus spores and the Attest Biological Incubator...

D. Sterility of the load is evidenced by the killing (failure to recover) of all spores on the biological indicators in the test pack.
E. Biological monitoring is carried out by following the manufacturer's instructions.
1. Documentation of this testing is maintained in a logbook.
2. The sterilization logbook is kept by the Attest Biological Incubator in the sterile processing room...

2. All biological testing is recorded and filed in a permanent log."

Review of the facility biological indicator test log book on 07/27/21 that the biological indicator test result were not documented daily per policy and regulations on the following dates for May to July 2021:
* 05/14, 05/17, 05/18, 05/19, 05/26, 06/02, 06/04, and 06/10.

The missing documentation of biological indicators were verified on 07/27/21 with the facility Director of Surgical Services