HospitalInspections.org

Based on staff interview, review of contracts, and job descriptions, it was determined the hospital's Governing Body failed to ensure contracted security services were provided in a safe and effective manner. This resulted in confusion as to the role of police who provided hospital security services. Findings include:

The hospital contracted with the City of Rexburg's police department to provide "security and other services." The agreement, dated 4/06/15, referred to a document titled "Madison Memorial Hospital/Protection Force Proposal." The proposal stated the police department would provide 1 armed on duty police officer and 1 Rexburg Police Department vehicle. The agreement stated the police department would provide "All weapons, equipment and uniforms for Officers..." The agreement further stated, "All personnel assigned to coverage will be fully certified to act as sworn officers of the Rexburg Police Department."

A job description for police who worked security was not present. Neither the agreement nor other documents defined the specific duties of officers stationed at the hospital. Neither the agreement nor other documents limited officers' ability to intervene with patients. For example, the agreement stated the police department would provide weapons and equipment. However, no document specified how police would use those weapons and equipment in the hospital. No document specified limits on the use of force for officers interacting with patients and visitors who exhibited belligerent or threatening behaviors.

A police officer, working security at the hospital, was interviewed on 6/26/18 beginning at 6:25 PM. He was in uniform and was armed. He stated a police officer was assigned to work 10 hours per day, 7 days per week at the hospital. He stated he thought the hospital had a job description for him as a security officer, but he was not sure. He stated, except for HIPPA training, he had not received specific training or orientation by the hospital, such as who was responsible to direct staff when patients displayed negative behaviors. He stated he did not know what system the hospital used for restraints.

The Engineering Manager was interviewed on 6/28/18 beginning at 2:30 PM. He stated the hospital had not developed job descriptions or training requirements for police officers who worked security at the hospital.

The hospital did not define the scope of services for contracted police officers.

Based on review of facility policy, medical records, and staff interview, it was determined the facility failed to ensure comprehensive POCs were developed for 10 of 27 patients (#18, #19, #29, #30, #35, #39, #41, #45, #46, and #47) admitted to inpatient or observation units and whose care plans were reviewed. This resulted in a lack of direction to staff caring for these patients. Findings include:

The hospital's policy "Med/Surg/ICU Plan of Care, effective 1/19/18, stated "Each patient will have a Plan of Care initiated by the admitting nurse and assigned in CERNER [electronic medical record]. Goals and Outcomes will be identified according to review of :

- Diagnosis
- Assessment
- Physician Orders
- Patient needs and requirements during stay
- Criteria for patient's discharge
- (Discharge planning begins at the time of admission)
- results of diagnostic tests"

This policy was not followed. Examples include:

1. Patient #18 was a 20 year old female admitted to the hospital on 3/07/18 at 7:41 PM, with a primary diagnosis of bipolar depression. Additional diagnoses included heroin abuse affecting pregnancy in third trimester and late prenatal care affecting pregnancy in third trimester. Patient #18 left against medical advice on 3/08/18 at 8:55 PM. Her record was reviewed.

Patient #18's record included a "History and Physical Report" dated 3/07/18 at 7:50 PM. The report stated "Upon admission, [patient name] had a nervous breakdown. A lot of her triggers from before came up and she wanted to leave AMA [against medical advice]...Currently she is really anxious, she is upset, claustrophobic, and feels trapped. She does feel some withdrawal symptoms coming up; mostly joint pain, myalgia, fatigue and restlessness."

Patient #18's record included a POC. The section of the POC titled "Nursing" included the plan "Knowledge Deficit Plan of Care," initiated on 3/08/18 at 6:54 PM. The outcomes on the POC included ability to understand the POC and medications. Interventions included identifying barriers to learning, assessing readiness to learn, assessing understanding of her condition, and instructing on disease process. It did not state what disease process would be taught. Patient #18's nursing POC did not include a plan, outcomes, or interventions related to her pregnancy, heroin abuse, withdrawal symptoms, pain, or anxiety.

During an interview on 6/28/18 at 9:20 AM, the Director of Medical/Surgical Services and the QTL reviewed Patient #18's record and confirmed her POC did not include plans to address her pregnancy, heroin abuse, withdrawal symptoms, pain, or anxiety.

Patient #18's nursing care plan was incomplete.

2. Patient #29 was a 19 year old female admitted to the hospital on 5/07/18 at 3:22 PM, with a primary diagnosis of pneumonia. Additional diagnoses included suicide attempt, depression, and migraine headache. She was transferred to a psychiatric hospital on 5/10/18 at 2:10 PM. Her record was reviewed.

Patient #29's record included a POC. It did not include a nursing POC. The section of the POC titled "Interdisciplinary" included the plan "Ineffective Airway Clearance," initiated on 5/08/18 at 5:57 AM. The outcomes on the POC related to maintaining her airway. There were no interventions on her POC. The POC did not include a plan, outcomes, or interventions related to Patient #29's suicidal thoughts, depression, or migraine headache.

During an interview on 6/28/18 at 9:25 AM, the Director of Medical/Surgical Services and the QTL reviewed Patient #29's record and confirmed her POC did not include plans to address her suicidal thoughts, depression, or migraine headache.

Patient #29's nursing care plan was incomplete.

3. Patient #30 was a 65 year old female who presented to the ED on 3/29/18 at 11:58 PM, and was admitted to the hospital on 3/30/18 at 1:53 PM, with a primary diagnosis of pulmonary emboli (blood clots in the lungs). Additional diagnoses included hypoxia (deficiency in the amount of oxygen reaching body tissue), respiratory distress, and nausea. Patient #30 died on 4/01/18 at 10:34 AM. Her record was reviewed.

Patient #30's orders included a hydromorphone pump which allowed her to self-administer pain medication intravenously. Her record included a pain assessment dated 3/31/18 at 9:00 PM. It documented left rib pain rated as a 10 on a scale of 0 to 10, with 10 being the worst pain.

Patient #30's record included a POC. The section of the POC titled "Nursing" included the plan "Activity Intolerance Plan of Care," initiated on 3/30/18 at 5:27 AM. The outcomes on the POC included increased activity tolerance. Interventions included assessing signs and symptoms of activity tolerance, providing undisturbed rest, and teaching self-monitoring, and pursed lip breathing.

Patient #30's POC did not include a plan, outcomes, or interventions related to nausea or pain.

During an interview on 6/28/18 at 9:15 AM, the Director of Medical/Surgical Services and the QTL reviewed Patient #30's record and confirmed her POC did not include plans to address her nausea or pain.

Patient #30's nursing care plan was incomplete.

4. Patient #35 was a 69 year old male admitted to the hospital on 6/24/18 at 10:27 PM, with a primary diagnosis of hypokalemia (low blood level of potassium). Additional diagnoses included abdominal pain and nausea and vomiting. He was discharged on 6/25/18 at 11:25 AM. His record was reviewed.

Patient #35's record included a Morse fall risk assessment completed on 6/25/18 at 8:03 AM. His Morse fall risk score was 45. The hospital's policy "Fall Prevention Procedure," effective 7/05/17, stated a score of 45 or greater demonstrated a high fall risk.

Patient #35's record included a POC. It did not include a nursing POC. The section of the POC titled "Interdisciplinary" included the plan "Impaired Tissue Integrity," initiated on 6/25/18 at 5:35 AM. The outcome on the POC stated "Verbalize Understanding of Condition and Causative Factors." There were no interventions on his POC. The POC did not include a plan, outcomes, or interventions related to Patient #35's pain, nausea and vomiting, or risk of falling.

During an interview on 6/28/18 at 8:40 AM, the Director of Medical/Surgical Services and the QTL reviewed Patient #35's record and confirmed his POC did not include plans to address his pain, nausea and vomiting, or risk of falling.

Patient #35's nursing care plan was incomplete.

5. Patient #39 was a 63 year old male admitted to the hospital on 6/24/18 at 4:19 PM, with a primary diagnosis of altered mental status. Additional diagnoses included DM type I and left foot pain. He was a current patient as of 6/28/18. His record was reviewed.

Patient #39's record included assessments of his risk of falling. An assessment completed on 6/24/18 at 7:12 PM, included a score of 45, indicating a high fall risk. His documented fall risk elevated to 70 on 6/25/18, and 85 on 6/26/18. Patient #39's record included a physical therapy assessment dated 6/25/18 at 4:34 PM. The assessment stated "Pt struggles with all mobility and movement. Pt requires significant assist with all transfers and gait. Pt is a fall risk..." A progress note dated 6/25/18 at 8:03 PM, signed by an RN, stated Patient #39 fell to the floor from his bed.

Patient #39's record included a POC. It did not include a nursing POC. The section of the POC titled "Interdisciplinary" included the plan "Knowledge Deficit...Patient [with] Cognitive or Sensory Limitation," initiated on 6/25/18 at 6:00 AM. The outcome on the POC stated "Participates in therapeutic regime." Interventions included "Barriers to Learning...Difficulty concentrating, Hearing deficit." Patient #39's POC did not include a plan, outcomes, or interventions related to his diabetes, pain, or risk of falling.

During an interview on 6/28/18 at 9:05 AM, the Director of Medical/Surgical Services and the QTL reviewed Patient #39's record and confirmed his POC did not include plans to address his diabetes, pain, or risk of falling.

Patient #39's nursing care plan was incomplete.

6. Patient #41 was a 50 year old male admitted to the hospital on 6/21/18 at 10:03 AM, with a primary diagnosis of cyclic vomiting syndrome. Additional diagnoses included left shoulder pain, dehydration, and diabetes. He was discharged on 6/27/18. His record was reviewed.

Patient #41's record included an "Adult Nutrition Initial Assessment/Plan" dated 6/21/18, signed by the Registered Dietician. It stated "Pt stated appetite poor over 5 days PTA [prior to admission], reported 12-15# Wt. [weight] loss over 5 days." Under recommendations to physicians it stated Patient #41 had a high nutrition risk.

Patient #41's record included a POC. It did not include a section titled "Nursing." The section of the POC titled "Interdisciplinary" included the plan "Ineffective Coping," initiated on 6/21/18 at 5:35 PM. The outcomes on the POC stated "Verbalize Awareness of Own Coping," "Verbalize Feelings and Meet Psychological Needs," "Assess Current Situation Accurately," and "Use Effective Coping Strategies." Interventions included "Identify Individual Stressors," "Encourage Verbalization of Fears, Anxieties," and "Provide for Gradual Implementation of Lifestyle changes." Patient #41's POC did not include a plan, outcomes, or interventions to address his vomiting, pain, or high nutrition risk.

During an interview on 6/28/18 at 8:50 AM, the Director of Medical/Surgical Services and the QTL reviewed Patient #41's record and confirmed his POC did not include plans to address his vomiting, pain, or high nutrition risk.

Patient #41's nursing care plan was incomplete.



39430

7. Patient #45 was a 82 year old female admitted to the hospital on 4/22/18, with a diagnosis of a fall. Additional diagnoses included hyperkalemia and acute renal failure. She was discharged on 4/23/18. Her record was reviewed.

Patient #45's record included a "History and Physical" dated 4/22/18 at 10:03 AM. The report stated "The patient has had a long-term issue with renal disease. Most recently, she has had an elevation in her BUN and creatinine. She had been stopped on all renal toxic medication, and it did not improve. She has had a generalized decline. She has recently been diagnosed with severe CHF."

Patient #45's record included a POC. The POC did not include a section titled "Nursing". The section of the POC titled "Interdisciplinary" included the plan "Risk for Injury". The POC did not include problems or interventions related to Patient #45's renal failure and CHF.

During an interview on 6/28/18 beginning at 10:58 AM, the Director of Medical/Surgical Services and the QTL reviewed Patient #45's record and confirmed her POC did not include problems or interventions related to her renal failure and CHF.

Patient #45's POC was incomplete.

8. Patient #46 was a 65 year old male admitted to the hospital on 3/15/18, with a diagnosis of Ischemic necrosis of right foot. Additional diagnoses included DM and ESRD. He was discharged on 3/19/18. His record was reviewed

Patient #46's record included an undated document titled "Problems". The document included the following problems:

- Hypertension.
- Left ventricular failure (heart failure).
- DM with complications.
- Muscle weakness.

Patient #46's record included a POC. The POC did not include a section titled "Nursing". The section of the POC titled "Interdisciplinary" included the plan "Impaired Tissue Integrity". This was the only plan listed under interdisciplinary. The POC did not include a problems or interventions related to Patient #46's DM, heart failure, hypertension, or muscle weakness.

During an Interview on 6/28/18 beginning at 10:30AM, the Director of Medical/Surgical Services and the QTL reviewed Patient #46 POC and confirmed his POC did not include problems or interventions related to DM, heart failure, or muscle weakness. She also stated it is the expectation that these issues would be addressed on Patient #46's POC.

Patient #46's POC was incomplete.

9. Patient #19 was a 67 year old female admitted to the hospital on 5/27/18, with diagnoses of hypoxia and dehydration. She was discharged on 5/28/18. Her record was reviewed.

Patient #19's record included a "History and Physical Reports" dated 5/27/18 at 12:54 AM. The report listed the following problems under the section titled "Assessment/Plan":

- Acute kidney injury
- Hypotension
- Encephalopathy acute
- Respiratory failure acute
- Chronic Pain

Patient #19's record included a POC. The POC did not include a section titled "Nursing". The POC did not include a problems or interventions related to Patient #19's acute kidney injury, hypotension, encephalopathy, respiratory failure, or chronic pain.

During an interview on 6/28/18 beginning at 11:05 AM, the Director of Medical/ Surgical Services and the QTL reviewed Patient #19's record and confirmed her POC did not include problems or interventions related to her acute kidney injury, hypotension, encephalopathy, respiratory failure, or chronic pain.

Patient #19's POC was incomplete.


37262

10. Patient #47 was an 86 year old female admitted to the hospital on 6/27/18, with a diagnosis of CVA. Additional diagnoses included hypertensive urgency and speech impairment. She was a current inpatient at the time of survey.

Patient #47's medical record included a history and physical, dated 6/27/18, signed by the physician, which included the secondary diagnoses of "hypertensive urgency and speech impairment."

Patient #47's medical record included a nursing POC, dated 6/27/18, signed by an RN. The POC included the identified issue "Impaired Communication." The POC did not address Patient #47's hypertension speech impairment.

The MS/ICU Clinical Coordinator was interviewed on 6/28/18, beginning at 2:45 PM, and Patient #47's medical record was reviewed in her presence. She confirmed Patient #47's nursing POC did not address her hypertensive urgency and speech impairment.

Patient #47's nursing POC was incomplete.

Based on contract review and staff interview, it was determined the hospital failed to ensure supervision and evaluation of non-employee hemodialysis nursing personnel. This had the potential for poor patient outcomes due to lack of contracted personnel oversight. Findings include:

A hospital contract "ACUTE DIALYSIS SERVICES AGREEMENT," dated 9/2012, stated "All Dialysis Center staff providing Services at the Hospital shall comply with all applicable infection control policies, quality assurance programs and other policies and programs which have been provided to the Dialysis Center in writing." This contract was not followed.

The Director of MS/ICU was interviewed on 6/27/18, beginning at 7:49 AM. When asked who supervised and evaluated non-employee hemodialysis nursing personnel, she stated she was unsure. The Director of MS/ICU confirmed there was no active oversight of contracted hemodialysis nursing personnel.

The Director of Quality Improvement was interviewed on 6/28/18, beginning at 2:35 PM, and the hemodialysis contract was reviewed in her presence. When asked what hospital policies, quality assurance programs, or programs were provided to the contracted hemodialysis nursing employees, she stated she was unsure. When asked if the CNO supervised and evaluated contracted hemodialysis nursing personnel, The Director of Quality Improvement stated no and confirmed there was no active oversight.

Non-employee hemodialysis nursing personnel were not supervised or evaluated.

Based on observation and staff interview, it was determined the hospital failed to ensure an acceptable level of safety and quality for wound care supplies in 1 of 2 outpatient departments (outpatient therapy services), whose department was observed and where wound care supplies were used. This had the potential for increased risk of patient infection and patient harm. Findings include:

A tour of the outpatient therapy services department was conducted with the Director of Therapy Services on 6/28/18, beginning at 10:35 AM. He stated physical therapists performed patient wound care and wound debridement within the therapy department. During the tour, the following wound care supplies were found to be expired:

- 1 package of Curity iodaform - expired 12/2016
- 3 packages of steri-strips - expired 9/2016
- 1 package of Replicare Thin - expired 5/2016
- 1 box of Acticoat - expired 9/2017
- 1 box of Acticoat - expired 4/2015
- 1 box of Acticoat - expired 10/2017
- 1 box of Tegaderm - expired 2/2018
- 1 box of Tegaderm - expired 10/2017
- 2 boxes of Tegaderm - expired 9/2016
- 1 box of Tegaderm - expired 11/2013
- 1 package of Tegaderm - expired 2/2018
- 5 packages of Xeroform gauze - expired 6/2016
- 1 package of Fibracol Plus - expired 5/2014
- 1 box of Mepitel - expired 9/2017

The Director of Therapy Services was interviewed on 6/28/18, beginning at 11:05 AM. When asked who was responsible for ensuring wound care supplies were not outdated, he stated "all employees, but primarily [name], PTA." When asked if he provided oversight to ensure expired wound care supplies were not available for patient use, he confirmed he did not and acknowledged there was no formal process in place.

The quality and safety of the outpatient therapy services department's wound care supplies were not ensured.

Based on hospital document review, observation, hospital policy review, and staff interview, it was determined the hospital failed to ensure the Infection Control Officer developed a system for identifying potential infections for patients and personnel. This had the potential for inadequate interventions to mitigate environmental and surgical infection control issues. Findings include:

The hospital failed to ensure environmental and surgical infection control issues were identified and addressed. Examples include:

1. Hospital sanitary conditions for patients, visitors, and staff were not maintained.

a. A tour of the NICU was conducted with the CNO and NICU charge nurse on 6/28/18, beginning at 9:05 AM. During the tour, the following infection control issues were noted:

i. A thick layer of dust was noted on shelving directly above multiple infant warmers/beds and the blanket warmer.

ii. A refrigerator, used to store breast milk, was noted to have accumulation of debris inside the grooves of the gasket and shelves. The NICU charge nurse was interviewed on 6/28/18, beginning at 9:05 AM and, when asked whose responsibility to clean the refrigerator, she stated she did not know.

iii. A hospital policy "Infection Control - Neonatal Intensive Care Unit (NICU)," effective date 11/10/17, stated "All NICU isolettes/Omnibeds/open warmers shall be cleaned and disinfected before any new infants are admitted according to department/manufacturer protocol and direction." This policy was not followed.

A container of concentrated Virex II 256 [a chemical disinfectant] was noted at the NICU nurses station. The manufacturers' instruction for use for the Virex II 256 stated "for use on hard, non-porous surfaces" and "minimum contact time of 10 minutes."

Two spray bottles of Virex II 256 were noted at the nurses station. The spray bottles were partially filled, with no date indicating when they were mixed. The NICU charge nurse was interviewed on 6/28/18, beginning at 9:15 AM. When asked what the Virex II 256 was used for, she stated it was for saturating the infant warmers/beds and mattresses (a porous surface) following patient discharge and PRN. The NICU charge nurse stated she would saturate the inside of the warmer and mattress with Virex II 256 and let the chemical stand for 8 minutes prior to wiping it off.

The CNO was interviewed on 6/28/18, beginning at 9:20 AM. He confirmed the presence of thick dust in the NICU, the soiled condition of the NICU breast milk storage refrigerator, and the use of Virex II 256 that did not follow the manufacturers' instruction for use.

The NICU failed to ensure environmental infection control issues were identified and addressed.

b. A tour of the MBU was conducted with the CNO on 6/28/18, beginning at 8:37 AM. During the tour, the following infection control issues were noted:

i. A thick layer of dust was noted to all horizontal surfaces above approximately 6 feet in height, including:

- patient room headboards
- patient room and unit shelving
- hanging pictures
- clocks
- medication Omnicell (medication dispensing device)
- ice machine

ii. The unit patient/visitor refrigerator was noted to have accumulated debris inside the grooves of the gasket. Additionally, the gasket was torn and in disrepair. The refrigerator shelves were noted to be stained and had accumulated debris as well. The MBU QTL was interviewed on 6/28/18, beginning at 8:46 AM. When asked whose responsibility it was to clean the refrigerator, she stated she did not know.

The CNO was interviewed on 6/28/18, beginning at 9:21 AM. He confirmed the lack of dust control on the unit and the disrepair and lack of cleanliness of the patient/visitor refrigerator.

The MBU failed to ensure environmental infection control issues were identified and addressed.

c. A tour of the MS/ICU was conducted with the MS/ICU Clinical Coordinator on 6/27/18, beginning at 1:30 PM. A thick layer of dust was noted to all horizontal surfaces above approximately 6 feet in height, including:

- refrigerators
- patient room and unit shelving
- hanging pictures
- clocks
- medication Omnicells
- ice machines

The MS/ICU Clinical Coordinator was interviewed on 6/27/18, beginning at 2:10 PM. She confirmed the lack of dust control on the unit.

The MS/ICU failed to ensure environmental infection control issues were identified and addressed.

d. A tour of the outpatient infusion center was conducted with the Director of Infusion Services on 6/28/18, beginning at 9:45 AM. During the tour, the following infection control issues were noted:

i. The unit patient/visitor refrigerator was noted to have accumulated debris inside the grooves of the gasket. The refrigerator shelves were noted to be stained and had accumulated debris. The Director of Infusion Services confirmed the refrigerator needed to be cleaned.

ii. The Director of Infusion Services stated patients in the outpatient unit could use hospital-provided electronic tablets to watch television and/or movies. When asked how these tablets were disinfected between patients, she stated they were cleaned with wipes. A stack of approximately 10 electronic tablets were noted in a cabinet, but it could not be determined which were clean and which were dirty. When asked if there was a policy or procedure which governed how these tablets were disinfected between patients, the Director of Infusion Services stated no.

The outpatient infusion center failed to ensure environmental infection control issues were identified and addressed.

e. A tour of the outpatient therapy department was conducted with the Director of Therapy Services and an EVS intern on 6/28/18, beginning at 10:35 AM. The unit consisted of several rooms and narrow hallways with a large, open therapy suite containing multiple pieces of therapy equipment. The unit had a large therapy pool and a room where wound care/debridement was performed; both adjacent to the therapy suite. The common areas and therapy suite were covered by carpet. When asked how the carpet in the unit was cleaned, the EVS intern stated he was unsure. A record of carpet maintenance for the unit was requested, but not provided by the end of the survey.

The outpatient therapy department failed to ensure environmental infection control issues were identified and addressed.

f. A hospital tour was conducted with the MS/ICU Clinical Coordinator, Director of MS/ICU, Executive Director of Ancillary Services, and EVS Supervisor on 6/27/18, beginning at 2:45 PM. During the tour, the following infection control issues were noted:

i. Numerous cloth chairs, couches, and patient-privacy curtains were noted throughout the hospital in patient rooms and exam rooms. When asked how these cloth items were disinfected, the EVS Supervisor stated they were sprayed with Virex II 256 and allowed to dry.

Virex II 256 manufacturers instruction for use stated it was to be used on "hard, non-porous surfaces" with a "minimum contact time of 10 minutes."

The EVS Supervisor, during the tour, confirmed the cloth items were not being disinfected with Virex II 256 according to manufacturers' instructions for use.

ii. Numerous ice machines were noted in multiple departments throughout the hospital. All ice machines observed had a buildup of minerals, discoloration, and debris noted to their ice dispensing plastic shrouds. It was unclear if the ice machines were sanitary for patient/visitor use.

The Director of Engineering Services and EVS Manager were interviewed together on 6/27/18, beginning at 2:45 PM. The Director of Engineering Services stated the ice machines underwent routine maintenance every 90 days, but confirmed they were "not cleaned as much as should be." Documentation of the ice machines cleaning schedule was requested from the EVS Manager, but was not provided by the end of the survey.

The hospital failed to ensure environmental infection control issues were identified and addressed.

2. Outpatient surgical center instrumentation sterilization was not maintained.

"AORN Guidelines for Perioperative Practice," 2015 edition, stated "Recommendation VII - 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. Immediate use steam sterilization should not be used as a substitute for sufficient instrument inventory. Sterilizer manufacturers' written instructions should be followed and reconciled with packaging and device manufacturers' instructions for sterilization." This guideline was not followed.

The May 2018 IUSS log for surgical instrumentation was reviewed. The log documented IUSS of surgical equipment on the following days:

- 5/01/18: 5 times
- 5/03/18: 3 times
- 5/08/18: 5 times
- 5/09/18: 1 time
- 5/10/18: 1 time
- 5/15/18: 5 times
- 5/21/18: 4 times
- 5/23/18: 4 times

The Surgical Center Manager was interviewed on 6/26/18, beginning at 8:40 AM, and the IUSS log was reviewed in her presence. She stated the surgery center used IUSS "daily for time saving." When asked what nationally recognized guidelines the surgery center followed for surgical procedures and instrumentation sterilization, she stated "AAMI and AORN." The Surgical Center Manager stated IUSS was mainly used for a specific physician's "surgical eye trays." When asked who made the decision to utilize IUSS for physician convenience, she stated her supervisor; the Director of Ambulatory Care Services.

The following devices, and their manufacturers' instructions for use regarding IUSS, were identified as part of the surgical eye trays:

- Ambler ophthalmic capsule polishers, ophthalmic forceps, ophthalmic manipulators, choppers, and hooks, cannulae, and ophthalmic gauges and corneal markers - "Immediate use steam sterilization (IUSS) should only be used for emergency reprocessing and should not be used for routine sterilization processing of instruments."

- Katena Reusable Ophthalmic Instruments - "Do not use flash [IUSS] sterilization to save time or as a substitute for standard instrument reprocessing. Flash sterilization cycling is designed to manage unanticipated, urgent needs for instruments."

A CST was interviewed on 6/26/18, beginning at 10:35 AM. She stated the surgery center had "2 sets of instruments for eyes, but could perform up to 15 eye procedures per day requiring these trays." When asked how these 2 trays were sterilized to accommodate the high number of procedures, the CST stated they were "flashed." When asked the reason these 2 trays underwent IUSS, she stated "used for cutting down drying time for cases and for physician convenience." The CST stated flash was used if there were more than 2 surgical cases in a day. When asked what nationally recognized guidelines the surgery center followed for surgical procedures and instrumentation sterilization, she stated "AORN."

The Director of Quality Improvement was interviewed on 6/27/18, beginning at 9:00 AM, and the outpatient surgery center IUSS log was reviewed in her presence. When asked for a policy which governed the hospital's use of IUSS, she stated "we don't flash here." The Director of Quality Improvement stated she was surprised the outpatient surgery center utilized IUSS for physician convenience.

The Director of Ambulatory Care Services was interviewed on 6/27/18, beginning at 10:15 AM. When asked why IUSS was used for physician convenience at the outpatient surgery center, she stated additional surgical eye trays were needed. The Director of Ambulatory Care Services stated the hospital identified this issue in January 2018. When asked, if the issue was identified 6 months ago, why the IUSS was still occurring, she stated it was due to an issue with the surgical eye tray purchasing contracts. When asked who was responsible for the surgical eye tray purchasing contracts, the Director of Ambulatory Care Services stated "the Director of Materials Management."

The Director of Materials Management was interviewed on 6/27/18, beginning at 11:50 AM. When asked if he was responsible for the surgical eye tray purchasing contracts, he stated no. The Director of Materials Management stated he was unaware of any issues with surgical eye trays and had no knowledge he had been tasked with acquiring new ones. He stated he was unsure if the CFO was aware of this issue or if any purchase requests had been sent to him.

The CFO was interviewed on 6/28/18, beginning at 2:41 PM. He stated he was unaware of any request or need for additional surgical eye trays. The CFO stated he would look into the matter and order new trays immediately if warranted.

The outpatient surgery center did not follow nationally recognized guidelines and manufacturers' instruction for use regarding surgical instrumentation sterilization.

3. Staff food and/or drinks were present in patient care areas.

a. A hospital policy "Infection Control - Neonatal Intensive Care Unit (NICU)," effective date 11/10/17, stated "Food is not allowed in the NICU area...Drinks should not be at the infant's bedside or in view of patient or visitors."

A tour of the NICU was conducted with the CNO on 6/28/18, beginning at 8:37 AM. During the tour, 2 staff drinks without lids and 1 partially eaten pastry were noted at the nurses station. These food items were in view of patients/visitors.

b. A hospital policy "Infection Control - Med/Surg/ICU," effective date 9/12/17, stated "Drinks with lids are allowed only when personnel are unable to take a break but must be kept in drawers or under the counter."

A tour of the MS/ICU was conducted with the MS/ICU Clinical Coordinator on 6/27/18, beginning at 1:30 PM. During the tour, 3 staff drinks without lids were noted at the nurses station.

c. A hospital policy "Infection Control - LDR & MBU, " effective date 4/26/18, stated "Drinks with lids are allowed only when personnel are unable to take a break but must be kept in drawers or under the counter."

A tour of the LDR & MBU was conducted with the CNO on 6/28/18, beginning at 9:21 AM. During the tour, 1 staff drink without a lid was noted at the nurses station.

The CNO was interviewed on 6/28/18, beginning at 9:21 AM. He confirmed staff food and/or drinks should not be present in patient care areas.

Hospital staff failed to ensure personal food and/or drinks were not present in patient care areas.

Based on hospital organizational chart review, surgical services meeting minutes review, and staff interview, it was determined the outpatient surgical center was not appropriately organized and integrated with inpatient surgical services. This had the potential for hospital employee confusion and impaired continuity of patient care. Findings include:

The hospital organizational chart, dated January 2018, listed the following on its chain-of-command:

- "Ambulatory Care Services" provided oversight to "Visiting Specialties," "[name] Clinic," and "Infusion Therapy."

- "Surgical Services" provided oversight to "Surgery," "Day Surgery," "Anesthesia," "Recovery," and the outpatient surgical center.

This organizational chart was not accurate.

The Surgical Center Manager, who was directly in charge of the hospital's outpatient surgical center, was interviewed on 6/26/18, beginning at 8:40 AM. She stated she did not have a clinical background and would rely on her charge nurses for clinical issues. The Surgical Center Manager stated the outpatient surgical center and inpatient surgical services were not integrated. She stated staff meetings between the two departments were separate and employees of the 2 departments rarely covered shifts between each other. Additionally, the Surgical Center Manager stated the outpatient surgical center and inpatient surgical services utilized 2 different sets of policies to drive their practice. She stated the hospital was in the process of merging the 2 policy sets into a single, cohesive reference. When asked who she reported to, the Surgical Center Manager stated "[name], Director of Outpatient Services." When asked if the Director of Outpatient Services was clinical, she stated no.

The Director of Surgical Services was interviewed on 6/27/18, beginning at 6:45 AM. When asked what her role was in regard to the outpatient surgical center, she stated none. The Director of Surgical Services stated she dealt exclusively with inpatients, not outpatients. She stated the outpatient surgical center "had no oversight" and the nurses who practiced there had to rely on each other for assistance. The Director of Surgical Services stated it was an area of concern that the Director of Outpatient Services was not clinical, the manager below her was not clinical, and her supervisor, the CFO, was not clinical. The Director of Surgical Services voiced frustration regarding lack of inclusiveness between the outpatient surgical center and inpatient surgical services.

The inpatient surgical services supervising CST was interviewed on 6/27/18, beginning at 7:06 AM. She stated inpatient surgical services had been trying to get their CSTs to train the outpatient surgical center CSTs since January 2018. When asked why, the supervising CST stated the outpatient surgical center CSTs believed "they don't have to follow guidelines since they're a freestanding ASC." She confirmed the outpatient surgical center and inpatient surgical services used 2 different sets of policies which was confusing to staff.

Surgical Services meeting minutes, dated March 2018, stated "Here and the surgery center. When someone is asked to go to the surgery center to work, remember their process flow is a little different. Be sure to over communicate and get clarification of their expectations. It is being reported that 'we' don't clean, wash instruments and move fast enough. [Director of Surgical Services] has requested from [Surgical Center Manager] that she allow some brief orientation time to follow [CST name] or [CST name] to better understand the process. Let's not have a turf war. With some communication and orientation we will all be on track."

The Director of Ambulatory Care Services was interviewed on 6/27/18, beginning at 10:15 AM. When asked if she went by the title "Director of Outpatient Services," she stated no. The Director of Ambulatory Care Services stated she, not the Director of Surgical Services, was over the outpatient surgical center. When asked if she had a clinical background, she stated no. When asked who the outpatient surgical center nurses would turn to for clinical questions, she stated the charge nurses or CNO. The Director of Ambulatory Care Services confirmed the hospital's organizational chart was not accurate. She stated the hospital was attempting to hire a clinical staff member to oversee both the outpatient surgical center and inpatient surgical services, but confirmed that had not yet happened.

The hospital's outpatient surgical center was not integrated with inpatient surgical services.