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Based on observation and interview, it was determined the Infection Control Nurse failed to identify and prevent infections in that a clean and sanitary environment was not provided for the patients on one (A) of two (A and B) Units toured. Failure to ensure the nursing unit was clean and sanitary had the potential to allow the sources of and transmission of communicable diseases. The failed practice affected all patients housed on Unit A on 04/18/18. Findings follow:

A. Observations on the A Unit on 04/18/18 included the following:
1) Observation of the Women's Hall showed two clear plastic wrappers on the floor on the left side of the hall between Rooms 237 and 238, and one wadded up paper ball on the floor next to Room 231.
2) At the end of Men's Hall on either side of the Room 225 door there were multiple dark stains on the floor, build-up of lint and hair at the baseboards and marks on the wall.
3) The alcove across from Room 228 had a build-up of lint and hair at the baseboards with multiple marks and stains on the alcove wall.
4) The Phone Area showed marks on the wall and a build-up of lint and hair on the floor at the baseboards.
5) The floor in front of Room 253 was filthy with multiple stains of different sizes and colors all along the entrance to Room 253.
6) Marks on the walls were observed between Rooms 254 and 252.
7) The floor in front of Room 258 showed multiple stains of different sizes and colors including brown and orange.
8) The floors on the entire unit, particularly where the baseboards and the floors met, were extremely dirty and stained.
B. The above was verified by the Unit A Nursing Manager at 11:30 on 04/18/18.


Based on policy and procedure review, risk assessment review and interview, it was determined the Infection Control Nurse failed identify and control infections in that an annual risk assessment was not performed annually per the policy and procedure titled "Infection Control Risk Assessment and Annual Plan," and failed to develop and implement a program for respiratory protection based on the annual risk assessment. Failure to perform an annual risk assessment did not allow the facility to be proactive in identifying the infection risk, the services provided, the population served, ways to decrease the infection risk, evaluation of methods used to decrease the risk of infection and formulation of a surveillance and protection plan. Failure to develop and implement a respiratory protection program had the potential to allow employee exposure to respiratory illnesses such as Tuberculosis with transmission to other patients and visitors. The failed practice had the potential to affect all patients, employees and visitors. Findings follow:

A. Review of the policy and procedure titled "Infection Control Risk Assessment and Annual Plan" received from the Chief Nursing Officer at 1:45 PM on 04/19/18 showed the infection prevention plan was to be updated at least annually and more often as changes in services and risks changed.
B. During an interview with the Infection Control Nurse at 10:50 AM on 04/19/18 she was asked for the Infection Control Risk Assessment for the last three to four years. Review of the Infection Control Risk Assessments received from the Infection Control Nurse at 11:00 AM on 04/19/18 showed only two (2012 and 2015) have been performed for the last six (2012-2017) years.
C. During an interview with the Infection Control Nurse at 2:30 PM on 04/18/18 she stated the Facility did not do employee Fit testing for respiratory protection.

Based on reviews of policy and procedure, manufacturer's guidelines, Biological Monitoring Log, observation and interviews, it was determined the Infection Control Nurse failed to identify and control infections in that the policy and procedure titled "Sterilization of Instruments" did not follow manufacturer's guidelines for the operation of the Midmark Self-Contained Steam Sterilizer; failed to control infections in that the Biological Monitoring Log did not contain the information required by facility policy and procedure; and failed to control infections in that the log contained inaccurate information which was not identified by staff. Failure to identify that the policy and procedure was not in congruence with the manufacturer's guidelines had the potential for sterilized items to be run for less than the recommended amount of time resulting in unsterilized items; failure to ensure the Biological Monitoring Log contained the required information did not allow the facility to track and trend problems, and failure to monitor the log did not allow the facility to be cognizant of staff failings and provide further education and training to ensure competent staff. The failed practices had the likelihood to affect any patient whose care required the use of the sterilized instruments. Findings follow:

A. Review of the policy and procedure titled "Sterilization of Instruments" received from the Infection Control Nurse on 04/18/18 showed once the instruments were properly cleaned and packaged, they were to be placed in the sterilizer and the POUCHES cycle was to be selected, and then the UNWRAPPED button was to be pressed.
B. Review of the Midmark Self-Contained Steam Sterilizer Installation and Operation Guide received from the Infection Control Nurse on 04/18/18 showed the UNWRAPPED cycle was to be used for unwrapped items which sterilized for a three minute period at 270 degrees Fahrenheit and the POUCHES cycle was to be used for wrapped items which sterilized for a five minute period at 270 degrees Fahrenheit. The findings in A and B were verified by the Infection Control Nurse during an interview at 9:15 AM on 04/19/19.
C. Review of the policy and procedure titled "Sterilization of Instruments" received from the Infection Control Nurse on 04/18/18 showed the following information was not documented on the Biological Monitoring Log as required per the policy and procedure:
1) The name or initials of the operator.
2) The response of the chemical indicator placed in load (biological indicator challenge test pack, biological indicator challenge test tray or chemical indicator challenge test pack), if applicable.
The findings in C were verified during an interview with Licensed Practical Nurse #1 at 10:20 AM on 04/19/18.
D. Review of the Biological Monitoring Log from 04/14/17 through 11/16/16 showed the following:
1) 18 (11/16/16, 11/28/16, 03/15/17, 03/15/17, 04/14/,17, 05/11/17, 06/02/17, 07/13/17, 08/17/17, 08/24/17, 09/22/17, 10/26/17, 12/01/17, 12/28/17, 01/25/18, 03/19/18, 04/02/18 and 04/04/18) of 21 (11/16/16, 11/28/16, 12/12/16, 12/27/16, 01/31/17, 03/15/17, 03/15/17, 04/14/,17, 05/11/17, 06/02/17, 07/13/17, 08/17/17, 08/24/17, 09/22/17, 10/26/17, 12/01/17, 12/28/17, 01/25/18, 03/19/18, 04/02/18 and 04/04/18) cycles run without documentation of the date placed in the incubator.
2) 21 of 21 (11/16/16, 11/28/16, 12/12/16, 12/27/16, 01/31/17, 03/15/17, 03/15/17, 04/14/,17, 05/11/17, 06/02/17, 07/13/17, 08/17/17, 08/24/17, 09/22/17, 10/26/17, 12/01/17, 12/28/17, 01/25/18, 03/19/18, 04/02/18 and 04/04/18) cycles run without documentation of the time placed in the incubator.
3) 16 (11/28/16, 03/15/17, 03/15/17, 04/14/,17, 05/11/17, 06/02/17, 07/13/17, 08/17/17, 08/24/17, 09/22/17, 10/26/17, 12/01/17, 12/28/17, 01/25/18, and 03/19/18) of 21 (11/16/16, 11/28/16, 03/15/17, 03/15/17, 04/14/,17, 05/11/17, 06/02/17, 07/13/17, 08/17/17, 08/24/17, 09/22/17, 10/26/17, 12/01/17, 12/28/17, 01/25/18, and 03/19/18) cycles run without documentation of the initials of the date and time placed in the incubator.
4) 21 of 21 (11/16/16, 11/28/16, 12/12/16, 12/27/16, 01/31/17, 03/15/17, 03/15/17, 04/14/,17, 05/11/17, 06/02/17, 07/13/17, 08/17/17, 08/24/17, 09/22/17, 10/26/17, 12/01/17, 12/28/17, 01/25/18, 03/19/18, 04/02/18 and 04/04/18) cycles run without documentation of the date and time out of the incubator along with the initials of the person performing the procedure.
5) 12 (11/16/16, 03/15/17, 03/15/17, 04/14/,17, 05/11/17, 06/02/17, 12/01/17, 12/28/17, 01/25/18, 03/19/18, 04/02/18 and 04/04/18) of 21 (11/16/16, 11/28/16, 12/12/16, 12/27/16, 01/31/17, 03/15/17, 03/15/17, 04/14/,17, 05/11/17, 06/02/17, 07/13/17, 08/17/17, 08/24/17, 09/22/17, 10/26/17, 12/01/17, 12/28/17, 01/25/18, 03/19/18, 04/02/18 and 04/04/18) cycles run without documentation of the type of sterilization.
6) 5 of (03/15/17, 03/15/17, 04/14/,17, 05/11/17, and 06/02/17) of 21 (11/16/16, 11/28/16, 12/12/16, 12/27/16, 01/31/17, 03/15/17, 03/15/17, 04/14/,17, 05/11/17, 06/02/17, 07/13/17, 08/17/17, 08/24/17, 09/22/17, 10/26/17, 12/01/17, 12/28/17, 01/25/18, 03/19/18, 04/02/18 and 04/04/18) cycles without documentation of minutes run.
7) 5 of (03/15/17, 03/15/17, 04/14/,17, 05/11/17, and 06/02/17) of 21 (11/16/16, 11/28/16, 12/12/16, 12/27/16, 01/31/17, 03/15/17, 03/15/17, 04/14/,17, 05/11/17, 06/02/17, 07/13/17, 08/17/17, 08/24/17, 09/22/17, 10/26/17, 12/01/17, 12/28/17, 01/25/18, 03/19/18, 04/02/18 and 04/04/18) cycles without documentation of temperature of run.
8) 9 (08/17/17, 08/24/17, 09/22/17, 10/26/17, 12/01/17, 12/28/17, 01/25/18, 03/19/18, and 04/02/18) of 21 (11/16/16, 11/28/16, 12/12/16, 12/27/16, 01/31/17, 03/15/17, 03/15/17, 04/14/,17, 05/11/17, 06/02/17, 07/13/17, 08/17/17, 08/24/17, 09/22/17, 10/26/17, 12/01/17, 12/28/17, 01/25/18, 03/19/18, 04/02/18 and 04/04/18) cycles documented as run 60 degrees Fahrenheit below the recommended temperature of 270 degrees.
E. The findings in 1-8 were verified during an interview with Licensed Practical Nurse #1 at 10:20 AM on 04/19/18.