HospitalInspections.org

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Based on observations and interview the facility failed to ensure preventative maintenance was completed on all patient care equipment. This failed practice placed patients at risk for inadequate care as a result of insufficient oversight of medical equipment. Findings:

Sharps

Observation on 3/23/16 at 9:50 am, 2 sharps containers located in the OR suite were found to be completely full.

During an interview on 3/23/16 at 9:50 am the Director of Clinical Services agreed the sharps containers were over the full line for safety of staff.

Preventative Maintenance (PM)
Observation on 3/22/16 at 9:40 am in room #3 revealed a Ohio suction machine on the emergency cart did not have a preventative maintenance identification number on it. In addition, the R-Series ALS defibrillator on the emergency cart was dated to be checked next on "9/15," indicating this machine was 6 months past due for a preventative maintenance check.

During an interview on 3/24/16 at 2:43 pm the Director of Maintenance stated the last time the PM contractor was in town he/she missed some equipment.


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Based on record review and interview the facility failed to ensure provision of services had been met; specifically, for infection prevention and control. Failure to ensure high level disinfection is done appropriately and policies are reviewed and approved by the Medical Director placed all patients at risk for transmission of infections. Findings:

Refer to citations C-272 and C-278


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Based on record review and interview the facility failed to review and/or revise policies on an annual basis. Lack of policy and procedure oversight, which facilitates the hospital's functionality, placed all current and future patients at risk of inadequate care and services. Findings:

Record review of the Quality Committee Minutes and Infection Control minutes provided for 2/2015-2/2016, revealed no documentation of policy approvals.

In addition those policies: "Infection Control and Prevention Program; CS 365 Cidex OPA Use; MetriCide Plus 30..." provided by the Director of Nursing, had no date or Medical Director approval.



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Based on record review and interview the facility failed to ensure a policy had been written defining the CAH services to include contracted services for any continued patient care and services. Findings:


During an interview on 3/24/16 at 10:30 am the Director of Nursing confirmed the facility did not have a policy defining what services were provided on site at the CAH and which patient care services were contracted out.





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Based on observation, interview, and record review the facility failed to ensure: 1) high level disinfectants were used according to manufacturer's guidelines in the Radiology Department and central sterile department; 2) laryngoscope blades were cleaned per manufacturer's guidelines and rust free; 3) sterile instruments were packaged and stored appropriately; and 4) the Infection Prevention & Control Program (IPC) provided facility wide surveillance of high level disinfection, sterility processes, and tracking and trending of surveillance data and implemented an antibiotic stewardship process. Failure to maintain surveillance of facility wide infection control practices and potential areas of infection risk placed all patients at risk for the transmission of bacterial infections. Findings:

High Level Disinfectant

Cidex OPA

Record review on 3/22/16 at 9:30 am of the facility's Cidex OPA (high level disinfectant) log book revealed the last date Cidex OPA was used was on 10/29/13, over 2 years before present survey.

During an interview on 3/23/16 at 1:10 pm, the Infection Control (IC) Nurse confirmed the last use of Cidex OPA was in the middle of February after 2 hernia surgical cases were completed. The IC nurse acknowledged the most recent use of Cidex OPA was not recorded in the Facility's Cidex OPA log book.

MetriCide 30

During interview and observation on 3/23/16 at 3:50 pm, the Radiology Tech stated that the radiology department uses MetriCide 30 (high level disinfectant) to clean vaginal ultrasound probes after use.

A MetriCide 30 log book was used to track the use. The MetriCide 30 log included the date, lot number, date activated, date de-activated, and technician responsible.

The log did not include solution temperature and immersion time.

Review on 3/24/16 of the facility's "MetriCide Plus 30..." policy, undated and unsigned, stated "Manufacturer's directions for activation and use and disposal will be followed."

Review on 3/24/16 of the MetriCide manufacturer's insert, provided by the facility, revealed for high-level disinfection "immerse medical equipment/device completely in MetriCide 28 or MetriCide 30 solution for a minimum of 90 minutes at 25 [degrees] C [Celsius], to destroy all pathogenic microorganisms..."

During an interview on 3/24/16 at 1:45 pm, the IC Nurse was not aware of the use of MetriCide 30 in the radiology department and could not speak to the cleaning process.

Laryngoscope blades

During observation on 3/23/16 at 9:50 am, Laryngoscope blades were found in the OR emergency cart. The blades were un-packaged and resting in a tray. Upon closer inspection, small amounts of a red/brown color could be seen on more than one blade. The color resembled that of rust.

During an interview on 3/23/16 at the same time as the laryngoscope blades observation, the Director of Clinical Services (DCS) was asked how the blades were cleaned. The DCS stated that Cidex OPA was used to clean the blades.
The DCS further stated that the blades were last used during a hernia repair operation within the "last couple of months".

Compromised packaging

Observation on 3/23/16 at 9:50 am, in the operating room cupboard revealed multiple compromised sterile packs of instruments. The packs had light brown markings that matched the outline of the instrument in the packaging and/or the racks from the autoclave. Markings could have been burn marks from the autoclave or rust marks from the autoclave racks.

During an interview on 3/23/16 at 9:50 am the DCS stated she was not sure what the markings were on the packaging but agreed the sterility was in question and the packs were pulled for re-sterilization.

Infection Control Committee

Review of the Infection Prevention and Control Nurse Job description, no date, revealed "...Responsibilities...Surveillance...identifies and monitors...specified...targeted surveillance...collects, monitors, and maintains records and data pertinent to surveillance...reports surveillance..."

Review of the "Infection Control and Prevention Program" no date, no approval, revealed "...Goal...to ensure the facility has a process in placed to reduce the risks of hospital acquired infections in patients...identification, investigation...antibiotic reviews...monitoring patient care practices...review of positive cultures...complete monthly IC /safety inspections..."

Review of the infection prevention meeting minutes for the previous 12 months revealed 2 meeting dates: 7/23/15 and 10/22/15. The minutes did not reflect surveillance, antibiotic use, culture data, or policy reviews. No data was provided at the time of survey for infection prevention surveillance.



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Base on record review the facility failed provide documentation of an annual review of all CAH services to include the volume of services.

During an interivew on 3/22/16 the Director of Nursing stated she was not aware of an annual review of the CAH scope of services to identifiy opportunities for growth or education.


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