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Based on observation and interview, it was determined the Infection Control Coordinator failed to ensure equipment was maintained to control the potential spread of infections in that two of two (upper and lower) water backflow preventers and drains in the central sterile decontamination room had a buildup of rust and the upper backflow preventer was leaking onto the lower backflow preventer. The failed practice did not ensure the equipment was maintained to prevent the spread of infection from cross contamination. The failed practice had the potential to affect all patients on which sterilized instruments were used. Findings included:

A. Observation on 06/19/18 at 1:15 PM showed the decontamination room had two (upper and lower) water backflow preventers with separate drains for each. The upper backflow preventer drain had a buildup of rust. The upper backflow preventer was leaking onto the lower backflow preventer. The lower backflow preventer shutoff valves and drain had a buildup of rust.
B. The findings of A were confirmed in an interview with the Supervisor of Surgery on 06/19/18 at 1:15 PM.

Based on review of the Medical Staff Rules and Regulations, clinical record review and interview, it was determined the facility failed to ensure the date and/or time of the surgery was documented in 12 (#1, #3-#12 and #14) of 15 (#1-#15) operative reports. Failure to document the date and time of the surgical procedure did not allow the facility to establish a time line of events that occurred during the patient's hospital stay. The failed practice affected Patient #1, #3-#12 and #14 and was likely to affect all surgical patients. Findings included:

A. Record review of the "Northwest Medical Center Medical Staff Rules and Regulation" on 06/20/18 showed the operative/invasive procedure report would contain the date and times of the surgery.
B. Review of Patient #1, #3-#12 and #14's clinical records on 06/20/18 showed the following:
1) Patient #1's surgical procedure was performed on 03/29/18. There was no evidence of the time of the procedure on the operative report.
2) Patient #3's surgical procedure was performed on 04/11/18. There was no evidence of the time of the procedure on the operative report.
3) Patient #4's surgical procedure was performed on 04/13/18. There was no evidence of the time of the procedure on the operative report.
4) Patient #5's surgical procedure was performed on 04/16/18. There was no evidence of the time of the procedure on the operative report.
5) Patient #6's surgical procedure was performed on 04/25/18. There was no evidence of the time of the procedure on the operative report.
6) Patient #7's surgical procedure was performed on 04/25/18. There was no evidence of the date or time of the procedure on the operative report.
7) Patient #8's surgical procedure was performed on 05/17/18. There was no evidence of the date or time of the procedure on the operative report.
8) Patient #9's surgical procedure was performed on 05/17/18. There was no evidence of the date or time of the procedure on the operative report.
9) Patient #10's surgical procedure was performed on 05/23/18. There was no evidence of the date or time of the procedure on the operative report.
10) Patient #11's surgical procedure was performed on 05/24/18. There was no evidence of the date or time of the procedure on the operative report.
11) Patient #12's surgical procedure was performed on 06/05/18. There was no evidence of the time of the procedure on the operative report.
12) Patient #14's surgical procedure was performed on 06/14/18. There was no evidence of the date or time of the procedure on the operative report.
C. The findings of A and B were confirmed with the Supervisor of Surgery and the Quality Director on 06/20/18 at 10:30 AM.