HospitalInspections.org

Based on document review and staff interview, it was determined that the hospital did not
(a) formulate and implement a policy and procedure to evaluate services provided to the facility through contracted services and (b) did not delegate responsibility for contracted services.

Findings include:

Tour and interview of staff of the Hyberbaric Service Area on 09/22/15 at approximately 12:00 PM, revealed that this service was provided to the patients by a management company.

Review of the Preventative Maintenance logs for the 4 Hyperbaric Chambers on 09/22/15 at approximately 12:30 PM, revealed that the staff did not consistently perform the weekly quality checks on all 4 chambers.

In addition, the Daily Checklist for the 4 chambers did not contain documented evidence of the tasks performed during shutdown, at the end of each treatment day. The checklists for all 4 chambers, on a daily basis, was observed to be left blank for proper shutdown procedures.

During interview on 09/22/15, Staff#7, Physician Director, stated that the technicians were responsible for chamber checks and that the technicians were trained to perform the Quality checks. This Physician was not able to comment on the missing documentation or on the performance of these tasks, as required by the manufacturer of the equipment.

Review of the 2015 Performance Improvement plan for 1st Quarter, revealed that the facility had noted the "Attestation record review" as 93.2% . There is no documented evidence of any actions taken to improve the rating..
The audit for "Chamber Safety" was documented as 100%. There was no information provided to indicate that audits included the performance of quality checks on a daily and weekly basis, including the completion of all required documentation.

Review of the "Contract Administration" policy revealed no evidence of a mechanism to ensure that all services provided under contract are evaluated. The policy failed to identify a systematic and ongoing assessment of the contracted service provided on-site, including but not limited to equipment maintenance; the policy does delegate responsiblty for contracted services.

Based on observation, document review and staff interview, it was determined the facility did not implement effective policies and procedures to provide a sanitary environment in the operating rooms and avoid sources and transmissions of infectious/ communicable diseases.

Findings include:

During observation of cleaning and preparing Operating Room #4 after a surgical case on 09/18/15 at approximately 11:30 AM, it was noted that the operating room housekeeping staff did not adhere to infection control practices to ensure effective cleaning of all equipment surfaces in the operating room.

There were two arm rests covered with tape. The operating room housekeeping staff did not remove the tape on these arm rests, instead, they wiped over the tape. The housekeeping staff also were observed using the same wipe over the surgical table and all other equipment.

The housekeeping staff failed to wipe down the surgical lights, the anesthesia machine, the IV pole and the blood pressure cuff. The anesthesia machine was observed to be dusty and stained.
These observations were made in presence of the Director of Facilities and the Nursing Director of Peri-Operative Services. The Operating room was re-cleaned by the same housekeeper under the supervision of the Director of Peri-Operative Services.

The soiled linen, the emptying of the biohazard buckets, the removal of the tubing from the anesthesia machine and sweeping of the floor was performed after the the operating room equipment were cleaned. The housekeeping staff member was not aware of sequence of tasks to be followed during the process of cleaning a dirty Operating room.

Upon interview of the housekeeper, it was revealed that he housekeeper did not receive training on cleaning the operating rooms.


Review of policies and procedures on 09/21/15, revealed that the facility did not have a comprehensive policy and procedure for terminal cleaning and for cleaning after each surgical case in the operating rooms.

Based on review of document and staff interview, it was determined the hospital did not track, analyze, trend and develop corrective action plans for Operating Room incidents involving breach in the infection control program.

Findings include:

Review of the Peri-Operative Patient Safety Events, recorded in "Quantros" database, conducted on 09/21/15 at approximately 2 PM, it was noted that few incidents of breach in sterile techniques and proper cleaning of equipment were identified from January through June of 2015.

Review of the Hospital Quality Assurance Committee Meeting Minutes, on 09/21/15 at approximately 3:00 PM, revealed that the hospital Quality Assurance Program does not track or trend these incidents.
During interview of Staff on 09/21/15, at approximately 3:30 PM, it was stated that the incidents involving physical environment and equipment of the operating rooms are discussed and tracked in the Peri-Operative Committee Meeting Minutes.

Review of the Peri-Operative Committee Meeting Minutes revealed that the hospital did not have documented evidence of any discussion of these incidents.
During interview of the Director of Peri-Operative Services, on 09/22/15 at approximately 2:00 PM, it was stated that these incidents were discussed during the Peri-Operative Committee Meetings and that the details of the discussions were not recorded by the secretarial staff in the meeting minutes.

The hospital failed to provide documented evidence of implementation a Quality Assurance Program, and monitoring of a corrective action plan for Peri-Operative Services.