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Based on observations, interviews and document review the facility staff failed to ensure the scrubs of staff worn in the sterile intravenous (IV) preparation (prep) room were laundered in a manner to prevent the spread of infections and hand-washing items were clean and free of possible contamination.

The findings include:

On 8/29/12, the pharmacy was observed at approximately 9:30 A.M., with the Director of Pharmacy and a Pharmacy Manager. The sterile IV prep room was observed. The Pharmacy Manager stated, "To enter the room beyond the red line (just inside door) the staff has to have on scrubs a surgical scrub gown, shoe covers, hair/head cover and mask. Once they enter the room they are to wash their hands."

While observing the room a staff member in brown scrubs was observed in the sterile IV prep room without a surgical scrub covering. As the staff member exited the sterile IV prep room she was asked if the hospital provided her scrubs and laundered them. She stated, "No, these are my scrubs and I launder them at home."

Once the sterile IV prep room was entered, a hand washing soap container was observed sitting in the sink and another empty one in the soap holder. The low lint towels used to dry hands after washing was observed sitting on the used red sharps container. To obtain a towel one had to reach down and into the box the towels were held in, possibly exposing the remaining towels to water dripping from the hands.

The Pharmacy Manager was asked about the staff members scrubs and stated, "That is not a problem due to the type of fabric the scrubs are made of." He did not know if the scrubs were made by the staff member or purchased. The Pharmacy Manager stated, "The soap is in the sink to prevent dripping and splashing water."

On 8/30/12 at approximately 12:35 P.M., the Infection Prevention Director (IPD) was interviewed and she stated, "We have a hand few of staff who are allowed to launder their scrubs at home due to allergies. We launder the scrubs then they take them home and re-wash to remove the detergent we use. We have a procedure we recommend they follow. I do not know if she is one of those few with allergies. The soap should not have been in the sink and the towels should have already been in a wall dispenser.

The IPD provided a document of the verbal instructions the staff are given who launder their scrubs at home. The document states the following: 1. Document allergy with Employee Health... 2. Secure a set of clean hospital supplied scrubs 3. Wash the clean scrubs at home -should be laundered separately and dried 4. Do not wear freshly laundered scrubs into the hospital; change after arriving at work site 5. Clean scrubs must be worn at the start of each shift.

The AJIC: American Journal of Infection ControlVolume 40, Issue 6 , Pages 539-543, August 2012 "Comparison of bacteria on new, disposable, laundered, and unlaundered hospital scrubs" states the following:
As a cost-saving measure, an increasing number of hospitals allow personnel to launder their uniforms, lab coats, and operating room scrubs at home. With rising nosocomial infection rates and increasing levels of multidrug-resistant bacteria in hospital settings, uniform contamination may be an environmental factor in the spread of infection.
We quantified the number and identity of bacteria found on swatches cut from unwashed operating room, hospital-laundered, home-laundered, new cloth, and new disposable scrubs.
Of the 29 unwashed hospital operating room scrub swatches analyzed, 23 (79%) were positive for some type of gram-positive cocci, with 3 (10%) of those classified as Staphylococcus aureus, and 20 (69%) were positive for coliform bacteria, 3 of which were Escherichia coli. Home-laundered scrubs had a significantly higher total bacteria count than hospital-laundered scrubs (P = .016). There was no statistical difference in the bacteria counts between hospital-laundered scrubs and unused new and disposable scrubs. In the home-laundered scrubs 44% (18/41) were positive for coliform bacteria, but no isolates were Escherichia coli.
Significantly higher bacteria counts were isolated from home-laundered scrubs and unwashed scrubs than from new, hospital-laundered, and disposable scrubs.

Based on review of the Life Safety Code survey report of the Life Safety survey which ended September 14, 2012, it was determined the hospital was not in compliance with 42 CFR Part 482: Conditions of Participation for Hospitals (Rev. October 11/2008) for Physical Environment.

Findings:

Please refer to the Life Safety Code report of September 14, 2012.

Based on observations and interviews the facility staff failed to ensure the environment was maintained in a clean and sanitary manner in the Emergency Department, Out-Patient Clinics, Radiology Department and the North Acute Psychiatric Unit.

The findings include:

1. During the initial tour of the facility on 8/28/12 at 8:55 A.M., with the Vice President of Support Services and Planning (VPSSP) the triage area of the Emergency Department (ED) was observed. The staff nurse (Employee # 149) assigned to the triage area was asked to explain the cleaning of the paper/single use blood pressure cuffs. Employee #149 stated, "I change them each morning."

One patient, Patient #22 was observed in the waiting area of the ED. Employee #149 was asked if Patient #22 had been triaged and Employee #149 stated, "Yes, he has." Patient #22 did not have a blood pressure cuff with him.

Behind the triage was an EKG room used for patient who complained of chest pain. The EKG machine had sticky tape residue on 3 of the 4 sides. Also in the room was an uncovered cart with clean ready to use sheets, patient gowns and towels.

On 8/28/12 at 9:55 A.M., the "fast track" area of the ED was observed. The dirty utility room contained a box of approximately 25 clean swabs used to obtain specimens for the detection of Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) and approximately 30 clean swabs used to obtain specimens for Strep (streptococcus) A test.
In the IV cart on the "fast track" side of the ED was approximately 30 vacutainers used for blood collection that had expired on various dates.
At approximately 10:45 A.M. on 8/28/12, the trauma room was observed. In Bay #1 of the trauma room, a pair of bloody shears hung over the gurney, which had a clean paper sheet over it for the next patient. The wheel at the top of the gurney had blood on it. In the air way cart in Bay #1 two initially sterile tracheal tubes available for use had been opened and replaced in the packaging.
In Bay #4 of the trauma area, the cart designated as the pediatric air way cart contained forceps in a torn package used for sterilization.
Also in the ED in the Green area room #15 contained a warmer/cooler that is used for warming and cooling patients, depending on the need. The warmer/cooler had several rusted and paint peeling areas making the surface unable to be cleaned after use.
In rooms in the ED (Green room #15, computer on wheels (COW) outside triage, room #12 of Pediatric ED) the computer keyboards did not have covers and/or did not have keyboards indicating they could be cleaned and disinfected after use in a patient room.
On 8/28/12, the radiology department was observed with the VPSSP. The cardiac cath lab area of radiology was observed at approximately 2:45 P.M. The x-ray table pad was observed after being clean to have a green sticky residue. The Supervisor of Interventional Radiology stated, "That is from dressings."
In the Ambulatory CT, MRI and ultrasound area the curtains in 1 of 4 patient changing rooms were stained and dirty.
On the Acute General Psychiatric Unit 1 of 10 shower curtains in patient room shower had an orange color on the shower curtain similar to the color of mildew.

The VPSSP stated, "We will get those things corrected before you leave."

On 8/30/12 at approximately 10:30 A.M., an interview was conducted with the Infection Prevention Director (IPD) in which all the above findings were shared. The IPD stated, "All of those things are a problem and most have been corrected already."

2. Two surveyors conducted observations of the facility's outpatient services on August 28, 2012 and August 29, 2012. Observations revealed direct care equipment, which did not have an intact surface and could not be disinfected between patients.
· An observation on the Pediatric Hematology/Oncology August 28, 2012 at approximately 10:00 a.m., revealed two (2) of four (4) examination tables observed had compromised covers. An interview was conducted with Staff #21 during the observation. Staff #21 acknowledged the findings. Staff #21 reported the compromised examination table covers could not be disinfected between patients.
· Observations of the orthopedic outpatient clinic conducted on August 28, 2012 at approximately 2:30 p.m. to 3:30 p.m. revealed four of six observed examination tables had tears and non-intact surfaces. Staff #148 acknowledged the findings. The clinical coordinator reported the non-intact surfaces prevented the disinfection of the examination tables between patients. The clinical coordinator acknowledged the risk of cross-contamination and the spread of infection since the examination tables could not be disinfected between patients.
· Observations of the neurological outpatient clinic conducted on August 28, 2012 at approximately 2:30 p.m. to 3:30 p.m. revealed three of five observed examination tables had tears and non-intact surfaces. Staff #42 confirmed the findings. Staff #42 reported the non-intact surfaces presented a risk for the spread of infections. Staff #42 acknowledged the tears prevented disinfection of the examination tables between patients.
· Observations conducted on the Ambulatory Care Center third floor on August 28, 2012 at 3:55 p.m., with Staff # 40 and Staff #148 revealed three of three observed examination tables had punctured and torn areas. Staff #40 acknowledged the findings.
· Observations conducted on the Ambulatory Care Center third floor surgery specialty services, on August 29, 2012 at 8:45 a.m., with Staff # 142, Staff #143, and Staff #148 revealed four of eight observed examination tables had torn areas. Staff #143 reported the tears prevented disinfection of the examination tables between patients and increased the risk for the spread of infection.

An interview conducted on 8/30/12 at 10:39 a.m., a surveyor met with the infection preventionist (IP) nurse to discuss the findings related to exam tables and chairs. The IP nurse acknowledged the tables and chairs in questions did have cracks or holes in them.






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