HospitalInspections.org

Based on review of the medical records of 21 patients, it was found that erroneous information was given regarding filing a complaint with the Department of State Health Surfaces.

Facility document entitled "Patient Responsibilities" which is signed by each patient upon admission stated in part "The physicians, nurses and entire staff of Physicians Surgical Hospital are committed to assure you reasonable care. Should you have a complaint or grievance related to Physicians Surgical Hospital, contact the Administrator at (806) 354-6100. If your complaint or grievance is not resolved to your satisfaction, you may contact the Director of Health Facility Licensure and Certification, Texas Department of Health, 1100 West 49th St, Austin, Texas 78756, (800) 227-1570.

21 of 21 medical records reviewed found in the Patient's Rights and Responsibilities section the wrong number listed to file a grievance with the Department of State Health Services. When called, it was found that the number listed was to a discount shopping program located in Draper, Utah.

The inaccurate information was confirmed by the Chief Clinical Officer on 8/18/15.

Based on review of documentation and interview, it was determined that the hospital failed to develop, implement and maintain an effective, ongoing, hospital wide, data driven quality assessment and performance improvement program.

Findings were:

Cross refer to:

A0273
A0308

In an interview with the Infection Control/Quality Improvement RN on 8/19/15, it was admitted that the hospital's current Quality Assurance Program was not effective.

Based on review of documentation and interview, it was determined that the facility failed to measure, analyze and track quality indicators throughout the hospital.

Findings were:

Facility document entitled "Quality Improvement Plan" stated in part "The plan's primary goals are aimed toward improving healthcare outcomes, reducing and preventing healthcare errors and assuring delivery of the same level of care.

The plan outlines the PSH-wide quality culture that focuses on designing processes to achieve optimal patient health outcomes in a collaborative, interdisciplinary approach. The process contains the following focus elements consistent with the hospital purpose, goals and values:

· Bases care on clinically sound evidence and standards.
· Incorporates information from internal and external sources to identify problems and to develop risk reduction strategies.
· Assesses services and items for which payment is made are reasonable and medically necessary.
· Assures that the same level of care is provided in a cost-effective manner consistent with the professional standards held in the medical community.
· Increases effective utilization of in-patient hospital services through an educational approach.
· Provides oversight of all quality of care."

No documented evidence was provided to the survey team to indicate that quality indicators were measured, analyzed and tracked throughout all departments of the hospital. This was confirmed in an interview with the Infection Control/ Quality Improvement RN on 8/19/15.

Based on review of documentation and interview, it was determined that the governing body failed to ensure that every department of the hospital was involved in its Quality Improvement Committee meetings.

Findings were:

Facility document entitled "Quality Improvement Plan" stated in part "The scope of quality improvement activities includes patient focused and organizational functions that impact quality improvement, patient safety, quality control, and resource utilization. The process includes monitoring, assessing and evaluating the quality and appropriateness of patient care, patient safety, clinical performance and utilization.

Collaborative, specific, objective and measurable indicators are designed based on current knowledge and evidence-based standards. The scope of these indicators includes monitoring, assessment and evaluation of, but not limited to:

· Blood product usage
· Care of high risk populations
· Environment of care and quality controls
· Infection control
· Management of information
· Medication Management
· Mortality review
· Operative/Invasive procedures
· Outcomes related to sedation and resuscitation
· Patient perception of care, safety and pain management
· Physician Peer Review
· Restraint use
· Risk/safety management
· Staffing effectiveness
· Utilization management
· CMS regulations and standards
· Core Measure Outcomes."

In an interview with the Infection Control/Quality Improvement RN on 8/19/15 it was admitted that Housekeeping, Radiology, Dietary and Maintenance departments were not involved with Quality Improvement Meetings.

Based on review of documentation and interview, it was determined that medical records in the facility are not being completed in a timely manner.

Findings were:

Facility policy entitled "Physician Orders" stated in part "Whenever possible, orders for drugs and biological shall be in writing, dated and signed by the individual responsible for the care of the patient. On those infrequent occasions when the telephone or verbal orders must be used for drugs or biological, the orders shall be accepted only by authorized personnel and shall be dated and timed and signed within 48 hours by the prescriber or another practitioner who is responsible for the care of the patient."

Review of 21 patient medical records revealed the following unsigned physician verbal orders:

Patient # 16 had the following unsigned physician orders:

· 7/25/15 @ 11:30 am
· 7/25/15 @ 18:30 pm
· 7/27/15 @ 09:40 am

Patient # 17 had the following unsigned physician orders:

· 7/29/15 @ (no time noted)
· 7/30/15 @ 09:00 am
· 7/30/15 @ 13:15 pm
· 7/30/15 @ 15:10 pm
· 7/30/15 @19:03 pm
· 8/1/15 @ 06:15 am
· 8/1/15 @ 06:30 am
· 8/1/15 @ 11:00 am
· 8/1/15 @ (no time noted)

In an interview with the Infection Control/Quality Improvement RN on 8/19/15, the unsigned physician orders were confirmed.

Based on observation and interview it was determined that medication refrigerators were not monitored for temperature ranges on a regular basis.

Findings included:

Facility policy entitled "Medications" stated in part "Medication Refrigerators:

1. Medications are properly and safely stored in medication refrigerator as needed.
2. The refrigerator should be equipped with a temperature alarm
3. Parameters should be set at 36-46 degrees."

Tour of the patient hallway on 8/18/15 found that the medication refrigerator in the medication room did not have a temperature log that was monitored daily.

· In January 2015, 10 days were missed
· In February 2015, 7 days were missed
· In March 2015, 6 days were missed
· In April 2015, 8 days were missed
· In May 2015, 9 days were missed
· In June 2015, 13 days were missed
· In July 2015, 8 days were missed
· As of 8/18/15, 6 days in August 2015 were missed.

In an interview with the Chief Clinical Officer on 8/18/15, it was admitted that refrigerator logs throughout the hospital were not checked daily. It was acknowledged that it is important to refrigerate medications according to manufacturer's recommendations and that refrigerator temperatures should be monitored daily.

Based on observation, interview, and record review the facility's Hospital #1 dietary department failed to provide an organized dietary services, failed to maintain the minimum standards of a sanitary food production environment and the food and dietetic services was not integrated into the hospital-wide QAPI and Infection Control program.
Findings included:

During a tour of Hospital #1's kitchen on the morning of 8/18/15 from 9:00 a.m. to 10:15 a.m., the following items were observed:

* A pan of cooked bacon and sausage was sitting at room temperature on top of the stove shelf.
* Three (3) uncovered trash cans containing trash in the food preparation area.
* Four (4) flies in the food preparation area and two (2) fly swatters were in the food production area.
* Two (2) floor drains with debris in the drain and on the floor, creating an environment for pests.
* Multiple items in the refrigerators and freezers removed from the original containers and not labeled and dated to ensure rotation for freshness.
* Raw vegetables were being prepared next to a sink with dirty pots and pans.
* Shelving in the reach in freezers and refrigerator with food debris and the freezer with ice buildup.
* The reach in freezer revealed a large bag of chicken hanging out of the door.
* The temperature logs for the freezers and refrigerators were missing recorded temperatures.
* Temperature logs for the dishwasher were missing recorded temperatures.
* The pull station for the fire alarm was blocked by stacks of canned soft drinks.
* The hot water sanitizing dish machine was not reaching the required temperature to sanitize the dishwares.

Review of the facility Registered Dietitian Reports reflected areas of improvement;
2/3/15 and 2/4/15 ...Foods not labeled/dated
3/3/15 and 3/17/15 ...Foods not labeled/dated
4/14/15 and 4/28/15 ...Foods not labeled and dated

During an interview on 8/18/15 at 9:00 a.m. Staff #20, Hospital #1's Dietary Manager stated
most of the cleaning was done on the weekend. He stated the Dietitian conducts sanitation
checks monthly and that he did not conduct formal inspections or record the findings or the
actions taken to correct the Dietitian's findings in the reports.

During an interview on 8/18/15 at 9:00 a.m. Staff #7, Hospital #1's Surgical Services
Director stated he is responsible for the oversight of the kitchen. He confirmed he received
the Dietician reports. He stated he reviews the reports but does inspect the kitchen for the
Dietitian's areas of improvement follow through. Staff #7 stated he did not present the
reports in the hospital QA meetings as he is dismissed and does not attend or participate in
the meeting.

Observations during a tour of Hospital #1's kitchen on 8/19/15 in the morning with Staff # 19
the Quality Assurance (QA), Infection control(IC) nurse revealed the continued practice of
three (3) uncovered trash cans, there were flies in the kitchen, there was unlabeled and dated
food items in the refrigerators and freezer (sandwiches, milk, chicken, salad, hamburger
meat), and salad was being prepared in a sink next to dirty soapy water.
Additional findings included:
* Temperature logs for the dishwasher were missing recorded temperatures.
* The pull station for the fire alarm was blocked by stacks of canned soft drinks.
* The hot water sanitizing dish machine was not reaching the required temperature to sanitize the dish wares.

Observation on 8/19/15 at 9:30 a.m. revealed Hospital #1's hot sanitizing dishwasher only
reaching 168 degrees Fahrenheit. The machine's posting reflected the minimum rinse
temperature at 180 degrees Fahrenheit. Staff # 20, the Dietary Manager was present.

Further observation revealed the facility's dietary department continued to use the dish
machine in spite of the fact that it was not sanitizing properly. Through the surveyors
intervention, the facility stopped using the machine and called in a service representative. The surveyor confirmed the dish machine was repaired and working properly prior to the exit conference.

Review of the facility Dish Machine Temperature Log dated August 2015 reflected:
* On 8/7/15, no temperatures was recorded for the dinner shift
* On 8/8/15, 8/9/15, 8/10/15, 8/11/15, 8/12/15, 8/13/15, 8/14/15, 8/16/15, 8/17/15, 8/18/15, and on 8/19/15, no temperatures had been recorded for the breakfast, lunch, and dinner shifts.

During an interview on 8/18/15 at 9:00 a.m. Staff #20, the Dietary Manager stated he did not check the dish machine temperature logs and was not aware the staff had not recorded the temperature for (12) days and could not say how long the dish machine had not been functioning properly. Staff #20 the Dietary Manager and Staff #19 the QA,IC Nurse confirmed the above findings.

Review of the facility provided policy #5.006 Food Storage (revised 8/11) reflected:
I. Policy: While being stored, prepared, displayed, served, or transported, food shall be protected from potential contamination, including dust, insects, rodents, unclean equipment, and utensils ...

Review of the facility provided HOBART dish machine operation manual reflected minimum water temperature for Hot water Sanitizing Mode Wash 150 degrees Fahrenheit and the Rinse at 180 degrees Fahrenheit.

Based on observation and interview, it was determined that the facility failed to provide a safe and sanitary environment for its staff and patients.

Findings were:

" OSHA/Blood Borne Pathogen Regulations Policy #138-030-060 " stated in part " The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner. "

Facility policy entitled "Food Storage in Refrigerators on Nursing Units" stated in part "Daily monitoring and recording of refrigerator temperature; cleaning of interior as needed; stocking; removal of outdated or inappropriately stored refrigerator items. Temperature logs will be done and retained." The policy continued "Employees may store their food only in employee-designated refrigerator."

Tour of Hospital # 1 during the morning of 8/18/15 revealed the following infection control issues:

· The waiting room had 5 vinyl covered chairs that were cracked and torn. These tears in the vinyl made cleaning the chairs impossible and cross contamination likely.
· The nourishment room in the patient hallway had a dirty refrigerator with spilled food in evidence. The cabinet contained patient snacks and employee dishes. The ice machine had calcium deposits dripping from the dispenser and needed cleaning.
· The medication room in the patient hallway had a 2/3s filled biohazard container on the floor. 4 empty vials were noted to be thrown on top of the container. There was staff medication stored in a drawer.
· The tub room found in the patient area next to the Pharmacy was dirty throughout. Staff food (cereal and peanuts) was found stored in the tub room. The Chief Clinical Officer said that the tub room was used for storage and no patients were bathed there.
· 2 unoccupied patient rooms were toured. In room # 1, a dead bug was found on the floor. The vent above the patient toilet had a black residue on it which could possibly be mold. In patient room # 2, unwrapped medical supplies (tubing) was found on a patient over-bed table. Placing a clean object on a dirty surface can cause cross contamination.
· In a second nourishment room, the ice machine had dust on the top and calcium buildup was noted coming from the dispenser. There was no temperature log on the refrigerator that housed patient food.
· Beds were noted outside of the surgical area that had tape on the railings. This tape made cleaning of the railing impossible.
· In the Emergency Department, a crib was found that was dirty. The Chief Clinical Officer stated that the hospital was planning to remove the crib from the hospital.

Tour of Hospital # 2 during the afternoon of 8/18/15 revealed the following:

· One of two lab draw chairs had a tear on the vinyl covering on the arm rest. This tear makes cleaning impossible and cross contamination likely.
· Shipping boxes were stored on shelving with clean supplies which could also cause cross contamination.
· Tape was found on a bed frame under a mattress in the pre-op area. An RN who worked in the area told the surveyors that "check sheets" for cleaning of the surgical beds was taped to the bed frames. Tape on the bed frames makes cleaning of the bed impossible.
· In the Pain Management room # 3, a chair was found that had dirty cloth tape on the bottom of 3 of the chair legs. This indicated improper cleaning of the area.

In an interview with the Chief Clinical Officer on 8/18/15, these findings were confirmed.

Based on observation, record review, and interview the facility failed to provide an organized surgical service in Hospital #1 and Hospital #2 when the facility;

· Did not provide cleanable equipment ;( 2) positioning boards and (5) rusted video carts.
· Routinely used flash sterilization without a policy and procedure.
· Stored (39) corrugated boxes in the operating room.
· Used a Pre-operative bed with 6 large pieces of surgical tape to hold the rail on.
· Failed to perform the daily and weekly cleaning of the autoclave Sterilizers and Washers.
· Failed to orient two (2) of two (2) Instrument Processing Technician (IPT)to the facility equipment

Hospital #1 findings included:

During a tour of Hospital #1, in the Operating room(OR) storage area on 8/18/15 at 11:00 a.m. revealed an arm positioning board with the side laminate missing and wood exposed and was not cleanable. The board had a multiple large strips of tape across the board that were discolored brown and stained. The storage room had (1) metal Valley lab cart with extensive rusting and two (2) video carts had rust on the base. Further observation in the room revealed (39) corrugated boxes, having the potential for pest to enter the OR.

During an interview on 8/18/15 at 11:00 a.m. in Hospital #1's clean sterilization room, when asked how she cleans the sterilizer autoclave, Staff # 17, Instrument Processing Technician (IPT) stated she drained the sterilizer. When the surveyor showed Staff # 17 the daily maintenance instructions included removing the drain screen and reverse rinsing it, she stated she does that also.

Further interview with Staff #17 on 8/19/15 at 10:30 a.m. she stated she performs the daily cleaning of the sterilizer washer, she drains the washer and the debris screen is cleaned and rinsed. She stated the maintenance department performs the weekly cleaning. Staff #17 confirmed she does not remove the manifold sliding inlet and inspect for debris. When Staff #17 was asked how she was trained on the sterilizer equipment, she stated she was not trained on the sterilizers she was already familiar with the equipment from another facility. She stated the maintenance personnel trained her on the cleaning of the washer. She was not aware of written instructions on the daily cleaning of the equipment. Staff #17 stated the weekly cleaning of the Autoclave and the Washer is performed by the maintenance department.

Review of Staff # 17's employee records dated 7/2/14 did not reflect training on the use of the facility's autoclave and washer.
During an interview on 8/19/15 in the Emergency Room, Staff # 7, the Director of Surgical Services confirmed that Staff #17 had not been trained or assessed for competency on Instrument Processing.

Review of the facility provided Flash Sterilization logs for Hospital #1 reflected:
On 8/4/15 Hospital #1 flash sterilized (13) items
On 8/5/15 Hospital #1 flash sterilized (2) items
On 8/10/15 Hospital #1 flash sterilized (3) items
On 8/11/15 Hospital #1 flash sterilized (12) items
On 8/12/15 Hospital #1 flash sterilized (9) items
On 8/13/15 Hospital #1 flash sterilized (5) items
On 8/14/15 Hospital #1 flash sterilized (7) items
On 8/17/15 Hospital #1 flash sterilized (7) items
On 8/18/5 Hospital #1 flash sterilized (3) items

During an interview, on a tour of Hospital #1's Operating room on 8/18/15, Staff #7, and Registered Nurse (RN) the Director of Surgical Services stated the facility does use Flash Sterilization. He stated the facility has decreased the use of Flash sterilization by at least 10%, but they still need to flash items due to an increase of cases and some of the physicians have specialized equipment that are not replaceable. We keep adding equipment and will continue to add equipment.

Hospital #2 findings included:

Observation during a tour on 8/18/18 at 2:00 p.m. of Hospital #2's operating room storage area revealed an arm board with cracked vinyl and large red stains. The storage room had (1) metal Valley lab cart with extensive rusting and three (3) Arthrex video carts with rust on the base.

Review of the facility provided Flash Sterilization logs for Hospital #2 reflected:
On 8/4/15 Hospital #2 flash sterilized (1) item
On 8/5/15 Hospital #2 flash sterilized (2) items
On 8/10/15 Hospital #2 flash sterilized (4) items
On 8/11/15 Hospital #2 flash sterilized (1) item
On 8/12/15 Hospital #2 flash sterilized (8) items
On 8/13/15 Hospital #2 flash sterilized (4) items
On 8/14/15 Hospital #2 flash sterilized (8) items
On 8/17/15 Hospital #2 flash sterilized (3) items
On 8/18/15 Hospital #2 flash sterilized (8) items

During an interview on 8/18/15 at 11:00 a.m. in Hospital #2's clean sterilization room, Staff# 18, IPT, when asked how she cleans the sterilizer, she stated she drains the sterilizer at the end of the day. Staff #18 confirmed she did not remove the drain, clean, or rinse the drain according to the manufacturer's instructions. When asked how she cleans the washers, she stated she removes the washer arms and cleans. Staff #18, IPT stated she did not remove the manifold sliding inlet and inspect for debris according to the manufacturer's instructions. Staff #18 stated the weekly cleaning of the Autoclave and the Washer is performed by the maintenance department.

During an interview on 8/19/15 at 11:00 a.m. Staff # 19, Quality Improvement, RN stated the facility did not have a policy or procedure on Flash sterilization.

Review of Staff #18's employee records dated 9/14/09 reflected a Clinical Core Assessment and Validation reflected the Staff #18 had not completed the facility sterilization competencies check.
During an interview on 8/19/15 at 11:45 a.m. Staff #29, Plant manager stated he does not train or in-service the personnel on the cleaning and maintenance of the sterilizer equipment. He stated his department conducts annual inspections and repairs the equipment as needed throughout the year. Staff #29 stated his staff performs weekly maintenance on the sterilizer equipment but he did not have documentation to support the activity. Staff #29 stated his department is responsible for the maintenance for both Hospital #1 and Hospital #2.
During an interview on 8/19/15 at 12:58 p.m. Staff #30, a maintenance employee stated he does daily checks of the sterilizers, looking at the functioning and pressure checks. He stated he does not clean the autoclave or washer.

Review of the facility provided Manufacturer instructions:
Each day clean washer as follows:
3. Remove sump debris screen from wash chamber and clean.
4. Rinse debris under running water. Note: Always clean debris screen while it is still wet,
before foreign matter dries.
5. Reinstall sump debris screen.
6. Remove manifold sliding inlet and inspect for debris.
7. Brush off and rinse under tap water, as necessary.

Steris Sterilizer 7.1.1 Clean Chamber Drain Strainer
Important: The chamber drain strainer must be cleaned at least once a day,
1. Remove the drain strainer from the drain in the bottom of the chamber ...
2. 2. Remove any obvious debris from the strainer. If necessary, clear the screen in the strainer using a brush, wire, or similar tool.
3. Once it has been cleared of obvious debris, reverse flush the strainer under running water

Review of the facility provided policy Pre-Vac Sterilizer, use, monitoring and Documentation (revised 2/14) reflected:
1.1 Steam sterilization by the unwrapped method is employed when there is insufficient time to sterilize an item by the preferred wrapped or container method in a steam sterilizer.

1.1.1 Pre-vac sterilization should be used in an emergency situation for individual items, such as an instrument that s dropped during a procedure and is needed to continue a surgical procedure, or on single specialized sets or other specialty items when there is insufficient time to process by the wrapped method.

Review of the Association for the Advancement of Medical Instrumentation. ANSI/AAMI ST79: 2010 & A1:2010-Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation, 2010 and
Recommended practices for cleaning and care of surgical instruments and powered equipment. In: Standards, Recommended Practices and Guidelines. Denver, CO: AORN, Inc; 2010 reflected,

Sterilization cycles with little or no dry time are efficacious when used in compliance with validated written instructions provided by the device manufacturers, sterilization equipment manufacturers, and (if applicable) container manufacturers and when done in accordance with professional guidelines.

Cleaning, decontamination, and rinsing are critical and users must follow and complete all required processing steps regardless of the sterilization exposure parameters being used.

Instrument inventories should be sufficient to meet anticipated surgical volume and permit the time to complete all critical elements of reprocessing.

Based on record review and interview the facility failed to provide written policies and procedures for Flash Sterilization (an abbrevieted sterilization process for surgical instruments needed immediately) and for the cleaning of the autoclave sterilizer and washer.

Findings included:


During an interview on 8/18/15 at 11:00 a.m. in Hospital #1's clean sterilization room, when asked how she cleans the sterilizer autoclave, Staff # 17, Instrument Processing Technician (IPT) stated she drained the sterilizer. When the surveyor showed Staff # 17 the daily maintenance instructions included removing the drain screen and reverse rinsing it, she stated she does that also.

Further interview with Staff #17 on 8/19/15 at 10:30 a.m. she stated she performs the daily cleaning of the sterilizer washer, she drains the washer and the debris screen is cleaned and rinsed. She stated the maintenance department performs the weekly cleaning. Staff #17 confirmed she does not remove the manifold sliding inlet and inspect for debris. When Staff #17 was asked how she was trained on the sterilizer equipment, she stated she was not trained on the sterilizers she was already familiar with the equipment from another facility. She stated the maintenance personnel trained her on the cleaning of the washer. She was not aware of written instructions on the daily cleaning of the equipment. Staff #17 stated the weekly cleaning of the Autoclave and the Washer is performed by the maintenance department.

During an interview on 8/18/15 at 11:00 a.m. in Hospital #2's clean sterilization room, Staff# 18, IPT, when asked how she cleans the sterilizer, she stated she drains the sterilizer at the end of the day. Staff #18 confirmed she did not remove the drain, clean, or rinse the drain according to the manufacturer's instructions. When asked how she cleans the washers, she stated she removes the washer arms and cleans. Staff #18, IPT stated she did not remove the manifold sliding inlet and inspect for debris according to the manufacturer's instructions. Staff #18 stated the weekly cleaning of the Autoclave and the Washer is performed by the maintenance department.

During an interview on 8/19/15 at 12:58 p.m. Staff #30, a maintenance employee stated he does daily checks of the sterilizers, looking at the functioning and pressure checks. He stated he does not clean the autoclave or washer.

During an interview on 8/19/15 at 11:00 a.m. Staff # 19, Quality Improvement, RN stated the facility did not have a policy or procedure on Flash sterilization.

During an interview on 8/19/15 in the morning Staff #7, the Director of Surgical Services confirmed the findings and did not provide autoclave and washer cleaning documentation.

Based on observation, record review, and interview the facility failed to provide an organized surgical service in Hospital #1 and Hospital #2 when the facility;

· Did not provide cleanable equipment ;( 2) positioning boards and (5) rusted video carts.
· Routinely used flash sterilization without a policy and procedure.
· Stored (39) corrugated boxes in the operating room.
· Used a Pre-operative bed with 6 large pieces of surgical tape to hold the rail on.
· Failed to perform the daily and weekly cleaning of the autoclave Sterilizers and Washers.
· Failed to orient two (2) of two (2) Instrument Processing Technician (IPT)to the facility equipment

Hospital #1 findings included:

During a tour of Hospital #1, in the Operating room(OR) storage area on 8/18/15 at 11:00 a.m. revealed an arm positioning board with the side laminate missing and wood exposed and was not cleanable. The board had a multiple large strips of tape across the board that were discolored brown and stained. The storage room had (1) metal Valley lab cart with extensive rusting and two (2) video carts had rust on the base. Further observation in the room revealed (39) corrugated boxes, having the potential for pest to enter the OR.

During an interview on 8/18/15 at 11:00 a.m. in Hospital #1's clean sterilization room, when asked how she cleans the sterilizer autoclave, Staff # 17, Instrument Processing Technician (IPT) stated she drained the sterilizer. When the surveyor showed Staff # 17 the daily maintenance instructions included removing the drain screen and reverse rinsing it, she stated she does that also.

Further interview with Staff #17 on 8/19/15 at 10:30 a.m. she stated she performs the daily cleaning of the sterilizer washer, she drains the washer and the debris screen is cleaned and rinsed. She stated the maintenance department performs the weekly cleaning. Staff #17 confirmed she does not remove the manifold sliding inlet and inspect for debris. When Staff #17 was asked how she was trained on the sterilizer equipment, she stated she was not trained on the sterilizers she was already familiar with the equipment from another facility. She stated the maintenance personnel trained her on the cleaning of the washer. She was not aware of written instructions on the daily cleaning of the equipment. Staff #17 stated the weekly cleaning of the Autoclave and the Washer is performed by the maintenance department.

Review of Staff # 17's employee records dated 7/2/14 did not reflect training on the use of the facility's autoclave and washer.
During an interview on 8/19/15 in the Emergency Room, Staff # 7, the Director of Surgical Services confirmed that Staff #17 had not been trained or assessed for competency on Instrument Processing.

Review of the facility provided Flash Sterilization logs for Hospital #1 reflected:
On 8/4/15 Hospital #1 flash sterilized (13) items
On 8/5/15 Hospital #1 flash sterilized (2) items
On 8/10/15 Hospital #1 flash sterilized (3) items
On 8/11/15 Hospital #1 flash sterilized (12) items
On 8/12/15 Hospital #1 flash sterilized (9) items
On 8/13/15 Hospital #1 flash sterilized (5) items
On 8/14/15 Hospital #1 flash sterilized (7) items
On 8/17/15 Hospital #1 flash sterilized (7) items
On 8/18/5 Hospital #1 flash sterilized (3) items

During an interview, on a tour of Hospital #1's Operating room on 8/18/15, Staff #7, and Registered Nurse (RN) the Director of Surgical Services stated the facility does use Flash Sterilization. He stated the facility has decreased the use of Flash sterilization by at least 10%, but they still need to flash items due to an increase of cases and some of the physicians have specialized equipment that are not replaceable. We keep adding equipment and will continue to add equipment.

Hospital #2 findings included:

Observation during a tour on 8/18/18 at 2:00 p.m. of Hospital #2's operating room storage area revealed an arm board with cracked vinyl and large red stains. The storage room had (1) metal Valley lab cart with extensive rusting and three (3) Arthrex video carts with rust on the base.

Review of the facility provided Flash Sterilization logs for Hospital #2 reflected:
On 8/4/15 Hospital #2 flash sterilized (1) item
On 8/5/15 Hospital #2 flash sterilized (2) items
On 8/10/15 Hospital #2 flash sterilized (4) items
On 8/11/15 Hospital #2 flash sterilized (1) item
On 8/12/15 Hospital #2 flash sterilized (8) items
On 8/13/15 Hospital #2 flash sterilized (4) items
On 8/14/15 Hospital #2 flash sterilized (8) items
On 8/17/15 Hospital #2 flash sterilized (3) items
On 8/18/15 Hospital #2 flash sterilized (8) items

During an interview on 8/18/15 at 11:00 a.m. in Hospital #2's clean sterilization room, Staff# 18, IPT, when asked how she cleans the sterilizer, she stated she drains the sterilizer at the end of the day. Staff #18 confirmed she did not remove the drain, clean, or rinse the drain according to the manufacturer's instructions. When asked how she cleans the washers, she stated she removes the washer arms and cleans. Staff #18, IPT stated she did not remove the manifold sliding inlet and inspect for debris according to the manufacturer's instructions. Staff #18 stated the weekly cleaning of the Autoclave and the Washer is performed by the maintenance department.

During an interview on 8/19/15 at 11:00 a.m. Staff # 19, Quality Improvement, RN stated the facility did not have a policy or procedure on Flash sterilization.

Review of Staff #18's employee records dated 9/14/09 reflected a Clinical Core Assessment and Validation reflected the Staff #18 had not completed the facility sterilization competencies check.
During an interview on 8/19/15 at 11:45 a.m. Staff #29, Plant manager stated he does not train or in-service the personnel on the cleaning and maintenance of the sterilizer equipment. He stated his department conducts annual inspections and repairs the equipment as needed throughout the year. Staff #29 stated his staff performs weekly maintenance on the sterilizer equipment but he did not have documentation to support the activity. Staff #29 stated his department is responsible for the maintenance for both Hospital #1 and Hospital #2.
During an interview on 8/19/15 at 12:58 p.m. Staff #30, a maintenance employee stated he does daily checks of the sterilizers, looking at the functioning and pressure checks. He stated he does not clean the autoclave or washer.

Review of the facility provided Manufacturer instructions:
Each day clean washer as follows:
3. Remove sump debris screen from wash chamber and clean.
4. Rinse debris under running water. Note: Always clean debris screen while it is still wet,
before foreign matter dries.
5. Reinstall sump debris screen.
6. Remove manifold sliding inlet and inspect for debris.
7. Brush off and rinse under tap water, as necessary.

Steris Sterilizer 7.1.1 Clean Chamber Drain Strainer
Important: The chamber drain strainer must be cleaned at least once a day,
1. Remove the drain strainer from the drain in the bottom of the chamber ...
2. 2. Remove any obvious debris from the strainer. If necessary, clear the screen in the strainer using a brush, wire, or similar tool.
3. Once it has been cleared of obvious debris, reverse flush the strainer under running water

Review of the facility provided policy Pre-Vac Sterilizer, use, monitoring and Documentation (revised 2/14) reflected:
1.1 Steam sterilization by the unwrapped method is employed when there is insufficient time to sterilize an item by the preferred wrapped or container method in a steam sterilizer.

1.1.1 Pre-vac sterilization should be used in an emergency situation for individual items, such as an instrument that s dropped during a procedure and is needed to continue a surgical procedure, or on single specialized sets or other specialty items when there is insufficient time to process by the wrapped method.

Review of the Association for the Advancement of Medical Instrumentation. ANSI/AAMI ST79: 2010 & A1:2010-Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities. Arlington, VA: Association for the Advancement of Medical I