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Based on interview, record review, and review of the hospital's quality program and quality documentation, the hospital and governing body failed to develop, implement, and maintain a hospital-wide, integrated QAPI program to which staff reported quality indicator data related to contamination in surgical instrumentation sets (1), failed to develop and monitor performance improvement actions through the hospital's quality program (2), failed to review, investigate, complete and analyze unusual event reports for patterns, trends, and common factors through the hospital's quality program (3), failed to provide oversight to ensure full implementation of the quality assessment and performance improvement (QAPI) plan (4), and failed to adhere to an effective infection prevention and control program (5).

Failure to systematically collect, analyze, assess, and monitor quality care indicator data limits the hospital's ability to formulate action plans for improvement and reduces the likelihood of sustained improvements in clinical care and patient outcomes.

Findings included:

1. Failure to develop, implement, and maintain a hospital-wide, integrated Quality Assessment Performance Improvement (QAPI) program that ensured quality indicator data related to sterile surgical set contaminants that were reported by the surgical services staff were reported to the hospital's quality program.

Cross-Reference A-273

2. Failure to develop and monitor performance improvement actions through the hospital's quality program.

Cross Reference A-0283

3. Failure to review, investigate, complete and analyze unusual event reports for patterns, trends, and common factors through the hospital's quality program.

Cross Reference A-0286

4. Failure to provide oversight to ensure full implementation of the quality assessment and performance improvement (QAPI) plan.

Cross Reference A-0309

5. Failure to adhere to an effective infection prevention and control program.

Cross-Reference A-0747

Failure to identify, track, aggregate and analyze data to determine factors that contribute to patient injury and ensure adequate resources to reduce risk to patients can result in an unsafe healthcare environment, risks patient harm, and risks delays and inadequate in care.

Due to the scope and severity of these deficiencies, the Condition of Participation at 42 CFR 482.21, Quality Assurance, and Performance Improvement was NOT MET.

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Based on interview, document review, and review of the hospital's quality program, the hospital failed to develop, implement, and maintain a hospital-wide, integrated Quality Assessment Performance Improvement (QAPI) program that received reports of quality indicator data related to contamination in surgical instrumentation sets.

Failure to systematically collect, analyze, assess, and monitor quality care indicator data limits the hospital's ability to formulate action plans for improvement and reduces the likelihood of sustained improvements in clinical care and patient outcomes.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Quality Plan 2018-2022," revised 02/19, showed the following:

a. The Board Quality of Care Committee oversees the quality of Providence Regional Medical Center Everett (PRMCE), and has delegated activities and monitoring of Quality and Patient Safety to the Quality Committee.

b. The PRMCE Quality Structure identifies essential committees, teams, and functions as part of the performance improvement structure including Infection Control Committee, Performance Improvement Teams, and Serious Safety Event Reviews.

c. Performance Improvement and Patient Safety Program information is presented monthly to the Quality committee.

d. The Quality Committee meets regularly to identify opportunities to improve quality and patient safety and monitor the status of potential Serious Safety Events to include but not limited to Adverse Events, Sentinel Events, and Caring Reliably Degree of Harm.

e. Collecting and analyzing data on performance, outcomes, and other activities are used to assist the hospital improve quality care, treatment, and services. Data is collected from performance improvement priorities identified by leaders, operative or other procedures that place patients at risk of disability or death, infection prevention and control, or through other data collected by teams and committees.

Document review of the hospital's policy and procedure titled, "Infection Control and Prevention Program Overview: Organization, Goals, Scope, Risk Assessment and Plan," policy number IC 01, no date, showed the Infection Control and Prevention (IC & P) Committee reports its findings and recommendations, including the annual risk assessment and plan, to the Medical Staff, the Chief Executive Officer, Regulatory Compliance, Service Line Performance Improvement Committees, Surgical Services Committee, and the Quality Committee.

2. On 01/07/20 at 2:40 PM, during an interview with Investigator #5, the Director of Perioperative Services (Staff #509) stated that the data related to the surgical instrumentation contaminants (black flake debris) had not been aggregated or analyzed because staff entry of variances in the Unusual Occurrence Reporting System (URO) was inconsistent and the hospital had begun using the Sterile Processing Module (SPM) to enter any issues with Sterile Processing including observations of black flake debris in the sterile surgical instrument trays. Staff #509 also stated that Risk Management reviews the reports and if a trend is observed it is reported to Infection Control and to the Executive Team.

3. On 01/08/20 Investigator #5 reviewed hospital documents from the hospital's internal data collection. The review showed:

a. The first reported case of surgical instrument tray contamination with black flake debris occurred on 12/19/17, when surgical staff observed black flakes in a surgical site after removal of instrumentation.

b. 31 reports of surgical instrument sets containing black flake debris (each report listing from 1 to 10 contaminated sets per report) from 03/26/19 through 11/19/19.

c. An elective surgical case where surgical staff identified black flake debris in the surgical instrument set and an elective surgical case where staff identified black flake debris on a scope. In both cases, the surgeon elected to use the instrumentation for the procedure.

4. On 01/08/20 at 9:37 AM, during an interview with Investigator #5, the Infection Control Manager (Staff #502) stated that she had only become aware of the black flake debris in the surgical instrument sets in the Fall of 2019 and that the information had not been reported to or reviewed by Infection Control Committee and was therefore not reported up to the Quality Committee.

5. On 01/09/20 at 9:10 AM, Investigator #4 and Investigator #5 reviewed the hospital's Quality Program and hospital documents. Investigator #5 found no evidence that the hospital's quality program received quality indicator data related to contamination in surgical sets from the surgical staff.

Investigator #5 found no evidence that any issues or concerns related to black flake debris in the surgical instrument sets, issues or concerns related to sterile processing processes or equipment, issues or concerns related to the use of these surgical instrument trays contaminated with black flake debris on surgical patients were reviewed or monitored as part of the hospital's Quality Program.

6. At the time of the Quality Program review, the Executive Director of Quality Care Systems (Staff #506) and the Quality Coordinator (#507) verified that aggregated and analyzed data related to the black flakes debris in the surgical instrumentation sets had not been reported to Quality Committee. Staff #507 confirmed that the identified issues had not been reviewed or monitored by the Quality Committee, but stated that many staff involved in investigating the issue were part of the Quality Committee team.

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Based on interview, review of the hospital's quality program, and review of quality documentation, the hospital failed to develop, implement, and maintain a hospital-wide, integrated Quality Assessment Performance Improvement (QAPI) program that included implementation and monitoring of performance improvement actions developed in response to the presence of contaminants in surgical instrumentation sets.

Failure to systematically collect, aggregate, and analyze quality indicator data developed in response to identified patient safety issues limits the hospital's ability to prevent medical errors and patient injuries and puts patients at risk of substandard care.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Quality Plan 2018-2022," revised 02/19, showed the following:

a. The Board Quality of Care Committee oversees the quality of Providence Regional Medical Center Everett (PRMCE), and has delegated activities and monitoring of Quality and Patient Safety to the Quality Committee.

b. Performance Improvement and Patient Safety Program information is presented monthly to the Quality committee.

c. Collecting and analyzing data on performance, outcomes, and other activities is used to assist the hospital improve quality care, treatment, and services. Data is collected from performance improvement priorities identified by leaders, operative or other procedures that place patients at risk of disability or death, Infection Prevention and Control, and from other data collected by teams and committees.

d. The Quality committee functions to prioritize the need for quality and operational improvement within the organization, balancing it with resources available, determining the reporting status of potential adverse events and overseeing action plans and progress reports of Failure Mode Effects Analysis (FMEA). The Quality Committee supports teams in accelerating achievement of the stated goals and objectives, and identifies opportunities to leverage best practice throughout the organization.

2. On 01/09/20 at 9:10 AM, Investigator #4 and Investigator #5 reviewed the hospital's Quality Program and hospital documents. Investigator #5 found no evidence the Quality Committee identified or implemented process improvement related to surgical instrument set contaminants reported by the surgical services staff.

3. At the time of the review, the Executive Director of Quality Care Systems (Staff #506) and the Medical Staff and Regulatory Affairs Director (#508) stated that the hospital had implemented an investigation and had taken signification actions since April 2019, after identifying it as a recurring issue. Staff #508 stated that the issue had not been formally brought to the Quality Committee, but that many members who were aware of the issue also sat on the Quality Committee.

Investigator #5 asked Staff #509 about the actions the hospital undertook to address the issue of the contamination since their data showed reports of black debris in surgical instrumentation for every month of reports between 03/19 through 11/19. Staff #507 stated that the hospital thought the issue had been resolved in April 2019 until a surge in reports of black flakes occurred again in June 2019. She stated that since the reoccurrence in June 2019, the hospital had taken additional steps including contracting with an outside agency to investigate the issue and through making changes in leadership. She also stated that on 12/30/19, the hospital instituted a multidisciplinary team that began meeting to address the issue.

During the interview, Investigator #5 reported that she had observed black flake debris in the surgical instrument set during her observation of a surgical procedure on 01/07/20.
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Based on interview, document review, and review of the hospital's policies and procedures, the hospital failed to use its quality program to investigate, ensure completion of unusual event reports and analyze the aggregated data for patterns, trends and common factors for 3 of 5 variance reports reviewed.

Failure to identify and analyze data to determine factors that contribute to patient injury can result in a delay in implementing measures to prevent/mitigate future deviations in care that negatively affect care and result in an unsafe healthcare environment.

Findings included:

1. Document review of the hospital's policy titled, "Unusual Occurrence (Event) Reporting Process," policy number 5758150, revised 12/18, showed the following:

a. An unusual occurrence is any event placing work force members, patients, or visitors at unplanned risk of harm or possible harm, any occurrence not consistent with routine operation of a healthcare system or the routine care of a particular patient. It may be an accident or situation, which might result in bodily injury or property damage.

b. An Unusual Occurrence Report (UOR) is the primary risk management reporting system for the hospital. Any occurrence at Providence that is inconsistent with the routine operations of the system or a particular patient should be reported through the UOR process.

c. UOR's are used to identify opportunities to improve the quality and safety of patient care, and advise the organizational leadership of problems or potential problems that could result in risk to the institution, staff and patients.

d. Events to report through the UOR process include all events or incidents of concerns to any employee, patient, or visitor, any event contrary to plans for, or implementation of, effective quality patient care.

e. The Manager or Designee will review all UOR's by the next available business day. The Manager will assess the seriousness of the event. If the event is more serious that initially recognized, they will immediately contact Patient Safety. In reviewing any event, the Managers always have the option to consult with Patient Safety.

f. Patient Safety will review all significant events, sentinel events, or near misses and all cases where Medical Staff is involved. Patient Safety has been delegated responsibility by the Community Ministry Board for oversight and for helping departments make improvements by providing timely data. Patient Safety provides regular feedback of UOR data to the departments and is available for consultation regarding display and interpretation of data.

Document review of the hospital's policy and procedure titled, "Quality Plan 2018-2022," revised 02/19, showed the following:

a. Performance Improvement and Patient Safety Program information is presented monthly to the Quality committee.

b. Collecting and analyzing data on performance, outcomes, and other activities are used to assist the hospital improve quality care, treatment, and services. Data is collected from performance improvement priorities identified by leaders, operative or other procedures that place patients at risk of disability or death, Infection Prevention and Control, and through other data collected by teams and committees.

2. On 01/09/20 at 8:39 AM, Investigator #5 and a Risk Manager (Staff #510) reviewed hospital UOR documents. Investigator #5 observed that the investigation of 3 of 5 reports reviewed were incomplete. Investigator #5 found no evidence the hospital completed an investigation for 2 of 2 reports reviewed where the use of surgical instrumentation sets contaminated with black debris were used on the patients undergoing a surgical procedure.

3. At the time of the review, Staff #510 confirmed that the investigations were incomplete and that the UOR data had not been reported to the Quality Committee. She stated that one of the reports was reviewed by the Surgical Committee because of Physician Behavior but did not address the use of the set contaminated with the black flakes.

4. On 01/08/20 at 9:37 AM, Investigator #5 reviewed the hospital's Infection Control Plan and the Infection Control Meeting Minutes for the year 2019. Investigator #5 found no evidence of data, data analysis, or process improvement activities obtained from the UOR's related to surgical instrument sets contaminated with black debris or the use of these trays on patients had been reported through the hospital's Infection Control Committee.

5. On 01/09/20 at 9:10 AM, Investigator #4 and Investigator #5 reviewed the hospital's Quality Program and hospital documents. Investigator #5 found no evidence data, data analysis, or process improvement activities obtained from the UOR's related to contaminated surgical instrument trays or the use of these trays on patients had been reported to the hospital's Quality Committee.

6. At the time of the review, Staff #510 verified that the reports had not been completed and that aggregated and analyzed data had not been reported to the Quality Committee.
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Based on interview and review of hospital documents, the hospital's Governing Body and Administrative Officials failed to provide oversight to ensure full implementation of the quality assessment and performance improvement (QAPI) plan.

Failure to provide oversight of the Quality Assessment and Performance Improvement program to ensure full implementation of the Performance Improvement Plan limited the hospital's ability to identify systemic problems and develop action plans to improve patient care and ensure safety in a timely manner.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Quality Plan 2018-2022," revised 02/19, showed that the Board of Directors bears the ultimate responsibility for oversight of the strategic quality direction for care provisions of all of its practitioners. The Board of Directors assures the achievement of the quality and patient safety vision and objectives. The Board of Directors has the responsibility to evaluate the effectiveness of quality and patient safety activities performed throughout the organization.

2. On 01/07/20 and 01/08/20, Investigator #5 reviewed the hospital's Quality and Infection Control Documents. Investigator #5 found no evidence the hospital's Infection Control Committee or Quality Committee reviewed or monitored data, information, or process improvement activities related to the contaminants in the surgical instrument sets.

3. On 01/09/20 at 8:15 AM, during an interview with Investigator #5, The Chief Nursing Officer (Staff #511) stated that the issues related to the black flake contamination in the surgical instrumentation sets had not been reviewed in the Quality Committee, but stated that the issue had been discussed in Leadership discussions. She also stated that she had discussed the issue with the Board of Directors "a couple of months ago" about Specialty Care (a contracted service) related to interest in getting leadership support for damaged surgical equipment. She also stated that the conversation had not been documented in the Board minutes.
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Based on document review and interview, the hospital failed to document justification for placing a subset of their medical equipment including steam sterilizers, under an Alternate Equipment Management (AEM) program.

Failure to fully document activities that contributed to the decision to move equipment into an AEM program, including incident history, failure history, qualifications of personnel involved in the decision, and potential for patient harm, puts patients at risk of injury from inadequate maintenance of equipment.

Findings included:

1. Document review of the hospital's policy titled, "Medical Equipment Management Plan", (last revised 04/17) showed that prior to placing equipment into an AEM program, qualified individual(s) will use written criteria including how the equipment is used, likely consequences of failure or malfunction , availability of back-up equipment and incident history.

2. On 01/08/20 between 8:45 and 9:30 AM, Investigator #4 interviewed the hospital's Facilities Manager (Staff #403) and the Clinical Engineering Manager (Staff #404) (via phone) about the hospital's biomedical equipment management. Staff #404 stated that some preventive maintenance for the hospital's steam sterilizers have been moved to an alternate equipment management program. The investigator asked if there was documentation for the decision. Staff #404 stated that it was discussed in meetings but not documented.

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Based on observation, interview, and document review, the hospital failed to ensure compliance with nationally recognized infection prevention and control precautions (1), failed to ensure a sanitary environment (2), failed to maintain medical waste containers in a way that reduced risk of harm from inadvertent needle sticks (3), and failed to develop and implement an effective infection prevention and control program that ensures appropriately cleaned, disinfected, or sterilized instruments (4).

Failure to adhere to an effective infection prevention and control program puts patients, staff, and visitors at risk of illness from communicable diseases.

Findings included:

1. Failure to document justification for placing a subset of their medical equipment including steam sterilizers under an Alternate Equipment Management (AEM) program.

Cross Reference: A-0724

2. Failure to clean a patient room consistent with hospital's policy for room cleaning after patient discharge

Cross Reference: A-0749

3. Failure to maintain medical waste containers in a way that reduced risk of harm from inadvertent needle sticks

Cross Reference: A-0749

4. Failure to ensure that the infection control officer developed and implemented a quality control system for the mitigation and control of healthcare-associated infections by ensuring medical instruments used for patient surgeries were sterilize according to hospital policy and national standards, and by monitoring the hospital's compliance with nationally recognized infection prevention and control precautions.

Cross Reference: A-0749

Due to the scope and severity of deficiencies cited under 42 CFR 482.42, the Condition of Participation for Infection Control was NOT MET.

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Based on observation, document review, and interview, the hospital failed to ensure that the infection control officer developed and implemented a quality control system for the mitigation and control of healthcare-associated infections by ensuring medical instruments used for patient surgeries were sterilized according to hospital policy and national standards, and by monitoring the hospital's compliance with nationally recognized infection prevention and control precautions (1), failed to clean a patient room consistent with hospital's policy for room cleaning after patient discharge (2), and failed to maintain medical waste containers in a way that reduced risk of harm from inadvertant needle sticks (3).

Failure to comply with recognized infection control and prevention guidelines and implement and manage elements of the hospital's infection control program puts patients, staff, and visitors at risk of illness from communicable diseases.

Findings included:

Item #1-Infection Quality Control Program: Surgical Instrument Set Sterilization

Reference: Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases (NCEZID), Division of Healthcare Quality Promotion (DHQP), "Factors Affecting the Efficacy of Disinfection and Sterilization: Guideline for Disinfection and Sterilization in Healthcare Facilities (2008)," reviewed 09/18/16, showed that organic and inorganic contaminants protect microorganisms from attack by acting as a physical barrier during the sterilization process.

1. Document review of the hospital's surgical guidelines titled, "Association of Surgical Technologists: Guidelines for Best Practice for Establishing the Sterile Field in the operating Room," revised 11/04/19, showed that upon opening a sterile package, commercial or sterilized in-house, if a foreign particle is identified within the package, the package must be considered non-sterile and not usable for the procedure. Foreign particles have been identified as contributing to post-operative complications including infections, adhesions, excessive scarring, delayed healing, granuloma formation, poor scar strength, and prolonged inflammation.

Document review of the hospital's policy and procedure titled, "Association of perioperative Registered Nurses: Guide for Sterile Technique-2019 Edition," publication date 2019, showed that organic and inorganic material that remains on a surgical instrument after the sterilization process is not considered sterile and may increase the risk of surgical site infection. Instruments should be considered contaminated when found with other debris including bone cement, grease, or mineral deposits on or in the instrument.

Document review of the hospital's policy and procedure titled, "Infection Control and Prevention Program Overview: Organization, Goals, Scope, Risk Assessment and Plan," policy number IC 01, no date, showed the following:

a. The Infection Control and Prevention (IC & P) Program was established to reduce the risk of healthcare- associated infections for personnel, patients, and visitors.

b. The IC & P Committee includes representatives from Nursing, Surgery, Safety & Environmental Care and Risk Management and these representatives participate in the assessment of the progress of key processes for controlling and preventing infection.

c. The IC & P Committee reports its findings and recommendations, including the annual risk assessment and plan to the Medical Staff, the Chief Executive Officer, Regulatory Compliance, Service Line Performance Improvement Committees, Surgical Services Committee, and the Quality Committee,

d. The IC & P Committee receives report from all other committees and departments regarding infection control and prevention problems, issues and findings.

e. The IC & P Committee and the IC & P Staff have a joint role in developing and implementing through administrative and department policies and procedures preventive and corrective steps designed to minimize infection hazards and consults on all phases of the institution's activities including construction and equipment purchasing.

f. The IC & P Committee and the IC & P Staff have a joint role in maintaining a permanent record of activities relating to infection control and submit periodic reports (e.g. meeting minutes) as needed to support communication and program function.

g. The IC & P Committee formally evaluates and revises the goals and program initiatives whenever risks significantly change and at least annually. This evaluation includes prioritization of the identified risks for acquiring and transmitting infections and evaluation of the plan's goals based on review of program activities. The evaluation included modifications of the scope of the IC & P program as necessary to support new services and new sites of care or changes identified by ongoing risk analysis. This assessment addresses limiting transmission of infections associated with procedures and limiting transmission of infections associated with the use of medical equipment, devices, and supplies

2. On 01/07/20 at 2:00 PM, Investigator #5 observed 2 Registered Nurses (Staff #504 and #505) open sterile instrument sets in preparation for a patient to undergo a surgical procedure. Investigator #5 observed Staff #504 open the sterile package containing the instrument set and remove the basket containing the instruments. The observation showed that Staff #504 opened the sterile package containing the instrument set and removed the basket containing the instruments. Staff #505 then wiped his hand over the inside and bottom of the instrument set and retrieved debris that appeared to be a black flake of unknown material.

3. At the time of the observation, Investigator #5 asked Staff #504 how long staff had been identifying the black debris contamination in the surgical instrument sets. Staff #504 stated that the black flake debris had been occurring for the entire timehe had been employed with the hospital, about 9 months. Investigator #5 asked Staff #504 when staff identified the black flake debris in the sterile surgical instrument sets, if the instruments were used on the patients. Staff #504 stated, "It is my preference not to, but it becomes the surgeon's decision."

4. On 01/07/20 at 3:30 PM, during an interview with Investigator #5, a Registered Nurses (RN) (Staff #501) stated that the sterile surgical instrument sets containing flakes of black material had been a problem for the past year. She stated that when surgical instrument sets are opened and they are observed to contain black flakes, the staff would try to get another set of sterile instruments. She stated that sometimes there are many sets that have the debris and they run out of instrument sets. She stated that if there were no more instrument sets, the decision to use instrument sets that containing the black flake debris is left up to the surgeon. She stated that she has worked in cases where surgeons used the instrument sets with the black flake debris even though staff stated they could not guarantee the sterility of the instruments.

5. Investigator #5 reviewed internal hospital documents. The review showed:

a. The first reported case of surgical instrument tray contamination with black flake debris occurred on 12/19/17, when surgical staff observed black flakes in a surgical site after removal of instrumentation.

b. 31 reports of surgical instrument sets containing black flake debris (each report listing from 1 to 10 contaminated sets per report) from 03/26/19 through 11/19/19.

c. An elective surgical cases where surgical staff identified black flake debris in the surgical instrument set and an elective surgical case where staff identified black flake debris on a scope. In both cases, the surgeon elected to use the instrumentation for the procedure.

6. On 01/08/20 at 9:37 AM, Investigator #5 reviewed the hospital's Infection Control Plan and the Infection Control Meeting Minutes for the year 2019. Investigator #5 found no evidence the hospital conducted an infection control risk assessment related to the surgical set contamination. Investigator #5 found no evidence in the minutes that the Infection Control Committee was aware or addressed the concerns related to the surgical instrumentation sets contaminated with the black flake debris.

7. At the time of the review, Investigator #5 interviewed the Infection Control Manager (Staff #502) about the Infection Control Committee's involvement with the issues related to the contamination in the surgical instrument sets. Staff #502 stated that the Infection Control Committee had not been involved in the investigation and stated that she had become aware of the black debris concerns in the Fall of 2019 when it was mentioned in passing that Sterile Processing was doing more evaluation on the washer disinfectors. She also stated that Sterile Processing was driving the investigation and that Infection Control had not been involved in the evaluations by (outside contractors) ECO lab or Nelco.

8. On 01/08/20 at 2:00 PM, during interview with Surveyor #5, the Medical Staff and Regulatory Affairs Director stated that the hospital had sent samples for analysis in April 2019 and in June 2019, they were determined to be non-biological, and not deemed an infection control issue.

9. On 01/08/20 at 3:00 PM, during review of the hospital's Infection Control Program, the Perioperative Director (Staff #509) stated that the Sterile Processing department reports issues during the daily Value Stream Management Huddle, but that Infection Control is not part of the daily huddle.

Item #2-Discharge Room Cleaning

1. Document review of the hospital's policy titled, "Discharge Room Cleaning", (last revised 03/19) showed that cleaning patient rooms after discharge included high dusting, performing hand hygiene after cleaning in the bathroom and before obtaining clean linens.

2. On 01/07/20 between 3:15 and 3:50 PM, Investigator #4 observed a member of the Environmental Services Staff (Staff #401) as she performed a "discharge cleaning" of patient room D628 on the Thoracic-Vascular unit. The observation showed the staff member commenced cleaning the room without completing a top to bottom high dust of the room's wall surface. The observation also showed the staff member completed cleaning in the patient bathroom and, without performing hand hygiene, changed gloves, and proceeded to clean the far side of the patient's room. The observation also showed that as Staff #401 cleaned items in a hanging wall basket, she put cleaned items back into the basket with non-cleaned items, creating potential for cross-contamination.

3. At the time of the observation, the investigator asked the staff member if she usually performed a high-dust of the room as part of the discharge room cleaning. She stated that she did, but she did not have a duster on her cart.

Item #3-Management of Sharps Containers

1. On 01/07/20 at 1:35 PM, Investigator #4 completed an environmental tour of the 6th Floor Medical Intensive Care unit. During the tour, the investigator entered a soiled utility room. The observation showed the container for sharps was overfilled and no longer usable.

2. On 01/07/20 at 3:50 PM, Investigator #4 observed cleaning of patient room D628 in the hospital's Thoracic Vascular unit. The investigator observed a wall mounted medical waste container with several scissors protruding from the container, rendering it unusable.

3. At the time of the observation in patient room D628, The investigator interviewed the Environmental Services Manager (Staff #402) about the process for maintaining the medical waste containers. Staff #402 stated that nursing staff are supposed to notify housekeeping if containers need replacement.
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