HospitalInspections.org

Based on observation, document review and staff interview it was determined the Hospital failed to ensure all radiological personnel shielding apparel was maintained and safe for use, potentially affecting all radiology staff and patients.

Findings include:

1. The Hospital policy dated 4/2015, titled, "C.T. SCAN UNIT AND SCOPE OF SERVICE" was reviewed on 4/19/16. The policy under "Safety of Patient and Personnel/Shielding 1." Para 5 "Proper safety precautions are maintained....Aprons and other shielding devices are checked annually for defects".

2. During an observation on 4/19/16 at 9:55 AM of Operting Room (OR) #3, a personnel shielding apron was noted to have a small hole with a black circle arount it on the left back side of the apron.

3. On 4/20/16 at 10:30 AM, an interview was conducted with the Director of Radiology (E #9). E #9 was able to locate the apron and verified the apron was compromised and should not have been used.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Sample Validation conducted on April 18 - 19, 2016, the surveyors find that the facility failed to provide and maintain a safe environment for patients and staff.
This is evidenced by the number, severity, and variety of Life Safety Code deficiencies that were found. Also see A710.

Based on observation during the survey walk-through, staff interview, and document review during the Life Safety Code portion of a Sample Validation Survey conducted on April 18 - 19, 2016, the surveyors find that the facility does not comply with the applicable provisions of the 2000 Edition of the NFPA 101 Life Safety Code.
See the Life Safety Code deficiencies identified with K-Tags on the CMS Form 2567, dated April 19, 2016.

Based on document review and staff interview, it was determined the Hospital failed to ensure a sanitary environment for surgical services to avoid sources and transmission of infections potentially effecting all patients receiving care in the Surgery Department.

Findings include:

1. On 4/19/16 at 10:00 AM, the Hospital's "immediate-use steam sterilization" (IUSS) spread sheet (Sep 2015 to Mar 2016) was reviewed. It indicated during the month of March 2016, 124 IUSS loads were performed for 1,099 surgical cases. The average rate for IUSS was 11.28%. The majority of the IUSS from 6/26/15 to 7/17/15 was for BIOM trays for vascular procedures.

2. On 4/19/16 at 10:00 AM, a tour of the Central Sterilization Department was conducted while being escorted with the Vice President, Nursing Services (E #4). During the tour, the Manager of central sterilization (E #6) verbalized IUSS is used quite often when the Hospital doesn't have enough instruments to handle the surgical case loads assigned that day, for that surgeon. E #6 also verbalized the Hospital follows the Association of PeriOperative Registered Nurses guidelines in reference to sterilization.

3. On 4/20/16 at 4:00 PM, Hospital policy "Immediate Use Steam Sterilization In The OR", last approved revision date 02/2016 was reviewed. Under "Statement:" it indicated "Unsterile instruments and items that are needed immediately in surgery may be sterilized (immediate use steam sterilization) within the department."

4. On 4/21/16 at 8:30 AM, the "2015 Edition Guidelines for Perioperative Practice" was reviewed. Under "Recommendation VII" indicated "Immediate use steam sterilization (IUSS) should be kept to a minimum and should be used only in selected clinical situations and in a controlled manner."

4. On 4/19/16 at 10:30 AM, an interview with E #6 and Vice-President Nursing Services E #4 was conducted. E #6 stated "We have been using IUSS since I started working here for the last 18 months." E #4 stated "The Hospital should only be using IUSS for emergency situations and if it's used because of lack of equipment, we will have to purchase more equipment. Our policy for immediate use steam sterilization in the OR needs to be revised."

Based on document review and staff interview, it was determined in 1 of 5 (Pt #13) surgical records reviewed, the Hospital failed to ensure the post-operative anesthesia evaluation was completed. This has the potential to affect all surgical patients.

Findings include:

1. The Hospital policy revision date 2/2016, titled, "DEPARTMENT OF ANESTHESIA SCOPE OF SERVICE" was reviewed on 4/19/16 at 10:00 AM. The policy under "Post-Anesthesia Evaluation" para. 1 "A post anesthesia evaluation on inpatients must be completed and documented by an individual qualified to administer anesthesia...".

2. The medical record of Pt #13 was reviewed on 4/18/16. Pt #13 was admitted for cardiac bypass surgery on 4/15/16. The post-operative anesthesia evaluation was not completed or signed by a qualified anesthesia personnel per policy.

3. On 4/18/16 at 2:30 PM, an interview was conducted with the Vice-President Nursing Services (E #4). E #4 reviewed Pt #13's medical record and post-operative anesthesia evaluation and verbalized, it was not completed or signed by anesthesia.