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Based on observation, interview, and record review, the facility failed to have an active hospital wide program for prevention of infections.

The facility failed to ensure the main Material management/supply storage room was kept in a sanitary manner.


Patient care and sterile supplies were removed from boxes and stored directly on shelves that were not sanitizable. The supplies were also underneath and next to shipping boxes in the Material management/supply storage room.


Personal protective equipment (PPE) was taken out of cardboard boxes and stored in open bins and on top of cardboard boxes putting them at risk for cross contamination.

Refer to A-tag 0749 for additional information.

Based on observation, interview, and record review, failed to employ methods as documented in their polices to prevent infections.

The facility failed to ensure the main Material management/supply storage room was kept in a sanitary manner.


Patient care and sterile supplies were removed from boxes and stored directly on shelves that were not sanitizable. The supplies were also underneath and next to shipping boxes in the Material management/supply storage room.

Personal protective equipment (PPE) was taken out of cardboard boxes and stored in open bins and on top of cardboard boxes putting them at risk for cross contamination.


This deficient practice had the likelihood to cause harm to all patients.



Findings:



During an observation on 11/10/2020 after 4:37 p.m., the following was found in the Material management/supply storage room:


Shelves of patient supplies were stored in shipping boxes and some had been removed from the shipping boxes and stored in open plastic bins.


Some of the shelves in the room were made of a particle board type of material and could not be sanitized. Supplies were found stored directly on the shelves.


Sterile supplies such as lumbar/epidural trays, intravascular catheter trays, indwelling Foley catheter kits, and sterile syringes shelves were not contained in anything and some were directly next to or stored underneath shipping boxes.


Respiratory supplies such as suction yankauers and suction containers were stored on the shelves underneath shipping boxes.


Personal protective equipment such as gowns and shoe covers was found in the room which had been removed from the shipping boxes. Some were in open plastic bins and some were in open bags on top of the shipping boxes.


Containers of Sanitizer wipes had been removed from their boxes and stored on a shelf.


Staff #4 ( Infection control preventionist) confirmed the observations.


Review of a facility's policy dated August 2019 named " Storage of Sterile Supplies" revealed the following:

"..3.1 Care in storage is as important as cleaning and proper packaging in ensuring the sterility of an item.

4.0 Procedure:

Procedure:

4.3 Make certain there is enough room in storage areas so supplies are not "jammed".

4.4 Sterile supplies must be stored away from solutions and other liquids to reduce the possibility of contamination ...

4.6 Unsterile items should not be stored next to sterile items.

4.7 They must be 6 inches from the floor and not within 18 inches of the ceiling, and two inches from the walls ..."


Review of American National Standards Institute (ANSI)/ Association for the Advancement of Medical Instrumentation (AAMI) ST79:2017 revealed the following:

"11.1 Sterile Storage

Sterile items should be stored under environmentally controlled condition that reduces the potential for contamination ...

Supplies should be removed from external and web-edged shipping container before transport to any restricted area ..."

"External shipping containers have been exposed to unknown and potentially high microbial contamination. Also, shipping cartons, especially those made of corrugated material; serve as generators of and reservoirs for dust." (AAM1 ST46-Section 5.2 Receiving items).