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Based on policy review and staff interviews; the hospital governing body failed to ensure oversight over contractual services by failing to ensure endoscopy reprocessing shared services were under contract.
The findings include:
Review of the hospital policy, "Endoscopy" with a revision date of June 2016 revealed, "I. PURPOSE: ... II. GUIDELINE: III. PROCEDURE: A. ...B. ...C. ...D. ...E. ...F. the ERCP (Endoscopic Retrograde Cholangiopancreatography-intestinal procedure )scopes from {Hospital 1} and {Hospital 2} would undergo Ethylene Oxide (Eton-gas) sterilization (cleaning). ... "
Interview during observational tours conducted September 9, 2015 at 0933 with Hospital staff #1 revealed the ERCP scopes were sent from the hospital to {Hospital 3} for gas sterilization.
Interview conducted September 10, 0215 at 1043 with Quality staff #1 revealed {Hospital 3} was an affiliation of the hospital corporate structure. Interview revealed the hospital and {Hospital 3} was not under the same provider number. Interview revealed there was no contract nor agreement between the hospital and {Hospital 3} for the EtO sterilization of ERCP scopes.
Interview conducted September 10, 2015 at 1103 with Hospital staff #1 and Quality staff #2 revealed high level disinfection of the ERCP scopes occurred at the hospital. Interview revealed the ERCP scopes were sent offsite for EtO sterilization. Interview revealed {Hospital 3} was part of the corporate structure and reported to the corporate level. Interview revealed the hospital and {Hospital B} did not operate under the same provider number and no contract nor agreement was available. Interview revealed the hospital did not have oversight of the ERCP scope cleaning at {Hospital 3}.

Based on policy review and staff interviews; the hospital staff failed to collect and analyze data for quality assurance to ensure the effectiveness of sterilization for the endoscopy scopes and failed to analyze data collected to monitor the effectiveness of terminal cleaning of 15 of 15 operating rooms by a contracted agency.
The findings include:
1. Review of the hospital policy, "Endoscopy" with a revision date of June 2016 revealed, "I. PURPOSE: ... II. GUIDELINE: III. PROCEDURE: A. ...B. ...C. ...D. ...E. ...F. the ERCP(Endoscopic Retrograde Cholangiopancreatography-intestinal procedure) scopes from {Hospital 1} and {Hospital 2} would undergo Ethylene Oxide (EtO-gas) sterilization (cleaning). ... "
Interview during observational tours conducted September 9, 2015 at 0933 with Hospital staff #1 revealed the Endoscopic Retrograde Cholangiopancreatography (ERCP-intestinal procedure) scopes were sent from the hospital to {Hospital 3} for EtO sterilization.
Interview conducted September 10, 0215 at 1043 with Quality staff #1 revealed {Hospital 3} was an affiliation of the hospital corporate structure. Interview failed to reveal the hospital staff collected and analyzed data for quality assurance to ensure the effectiveness of EtO sterilization for the ERCP scopes.
Interview conducted September 10, 2015 at 1103 with Hospital staff #1 and Quality staff #2 revealed high level disinfection of the ERCP scopes occurred at the hospital. Interview revealed for two (2), the ERCP scopes were sent offsite for EtO sterilization. Interview revealed an indicator (monitoring device) would be placed on the inside and on the outside of the locked case. Interview revealed the locked case would be delivered and leave the hospital by the processing department. Interview revealed after offsite EtO sterilization, the locked case would return back to the hospital by the processing department. Interview revealed the indicators would be assess for sterilization assurance. Interview revealed the hospital staff failed to analyze data for quality assurance to ensure the effectiveness of Eto sterilization for the ERCP scopes performed at {Hospital 3}.

2. Review of the "NIGHTLY OPERATING ROOM CLEANING RECORD" revealed "all terminally cleaned rooms must pass inspection and be signed off by the Operating Room Assistant, Housekeeping Technician and the Operating Room Supervisor to be considered clean.
Review of the "END OF DAY / TERMINAL CLEANING LOG" revealed the end of day duties must be performed in accordance with the Association of Perioperative Registered Nurses (AORN) recommended practices.
Review of the terminal cleaning log for August 17, 2015 through August 21, 2015 (five days); August 24, 2015 through August 28, 2015 (five days) and August 31, 2015 through September 4, 2015 (five days) revealed 15 of 15 operating rooms were in use. Review revealed the housekeeping technician, the OR Assistant and the OR supervisor initials were documented for 10 of 15 days.

Interview conducted September 10, 2015 at 1345 with Surgical Services Educator and Surgical Services personnel revealed the data was being collected. Interview revealed no analysis of the collected data was performed to monitor the effectiveness of terminal cleaning by a contracted agency.

Based on policy review, observation during tours and staff interviews, the hospital nursing staff failed to date and time intravenous tubing for surgical services patient scheduled for 1 of 1 a procedure (Patient #14).
The findings include:
Review of the hospital policy, "IV TUBING CHANGE, SITE CARE, DRESSING CHANGE, and REMOVAL" with a revision date of March 2015 revealed, "I. POLICY A ...B ...C. IV TUBING - administration sets will be changed as follows: 1 ...2 ...3 ...4 ...5 ...6 ...7. Label IV tubing with IV set change sticker with start date/time ... "
Observation during tours conducted September 9, 2015 at 1005 revealed Surgical Service Area #1. Further observation revealed the pre-operative area consisted of 23 patient care areas. Observation revealed IV medication was located in patient care area #1 and no patient was located in patient care area #1. Further observation revealed the medication was Vancomycin (antibiotic) 1500 milligrams (mg) in 250 milliliters (ml) of solution. Further observation revealed the IV tubing was primed (removing air from the IV tubing with medication). Observation failed to reveal the IV tubing had an IV set change sticker.
Interview conducted September 10, 2015 at 1237 with Surgical Services Nurse #1 revealed the patient assigned to patient care area #1 was scheduled for a Left Total Hip Replacement (surgical procedure). Interview revealed a second surgical service nurse primed the IV tubing. Further interview revealed registration was called but the patient was not ready to come back to the pre-operative area. Interview revealed the IV tubing was not properly labeled.
Interview conducted September 10, 2015 at 0949 with the Pharmacist and the Infection Preventionist revealed medication should be spiked at the time two (2) patient identifiers have occurred and when the patient is in the patient care area. Interview revealed when a healthcare personnel is unable to determine when the IV tubing was primed, the IV tubing with the medication should be discarded. Interview revealed the IV tubing was not properly labeled.

Based on observation during unit tours and staff interviews, the hospital staff failed to maintain a clean physical environment to prevent transmission of disease in 2 of 3 bathrooms and ensure blood glucose monitors are cleaned and disinfected following patient use in 5 of 5 monitors on 1 of 4 units toured.

Findings include:

1. Observation during unit tour on 09/09/2015 at 1010 revealed 2 of 3 patient bathrooms, one room occupied and one ready for admission, had a brown substance noted on the handrail used by the patient to help pull themselves up from the commode. Observation of the occupied room revealed a thick layer of the brown substance near the elbow of the handrail that was easily removed with a dampened paper towel. Observation of the patient care room ready for admission revealed a layer of brown substance in the same location as previously indicated that was also easily removed with a dampened paper towel.

Interview with the unit nurse assisting with the tour on 09/09/2015 at 1035 revealed the brown substance in the occupied room "looks like fecal matter." Interview regarding the brown substance identified in the room ready for admission "looks like the same situation/substance as the other." Interview revealed it was not a common finding or complaint and indicated Environmental Services would be notified immediately.

Interview with the Director of Environmental Services 09/09/2015 at 1110 revealed each occupied room is cleaned daily, including the patient's bathroom. Interview revealed managers round daily to inspect the effectiveness of the house keeper and to evaluate trial chemicals being considered for purchase. Interview revealed the elbow area of the handrail is "not a common area inspected but will be going forward."

2. Observation during unit tour of the nursing blood sugar docking stations on 09/09/2015 at 1045 revealed five (5) blood glucose monitors in total, two (2) at nursing station number one (1) and (3) docked in nursing station number two. Observation of monitors docked in station one revealed monitor number one contained two red colored, circular spots on the area surrounding the strip access and monitor number two contained three brownish-red circular and smeared spots area the area surrounding the strip access. Observation of monitors docked in station two revealed monitor number three contained one droplet of a bright red substance directly in the center of the glass scanning mechanism, monitor number four (4) contained eight (8) brownish-red spots located on the front of the monitor, near the top of the device and around the area surrounding the strip access. Areas were also noted on the back of the devise as well and monitor number five (5) contained two brownish-red smeared areas near the area surrounding strip access. Observation revealed the hospital staff failed to ensure the blood glucose monitors were cleaned after patient each patient use.

Interview with unit nurse assisting with unit tours 09/09/2015 at 1045 revealed the areas "looked like blood". Interview revealed the expectation is to "clean each device following patient use and between patients." Interview revealed the findings were "not the hospital's practice" and "did not help prevent the spread of infectious disease." Interview revealed hospital policy was not followed.

Interview with the nurse manager 09/09/15 at 1045 of the unit revealed the findings were not the expectation. Interview revealed the hospital's policy was not being followed and the findings were not acceptable. Interview revealed the monitors should be cleaned between patients to prevent the spread of infectious disease. Interview revealed hospital policy was not followed and the "current practice was not acceptable.

NC00109687