HospitalInspections.org

Based on clinical record reviews, review of facility policies and procedures and interviews, the facility failed to ensure that surgical equipment was disinfected in accordance with manufacturer's recommendations and/or the hospital failed to maintain a patient tracking mechanism for processed surgical equipment and/or that infection control practices in the operating room were followed in accordance with facility policy/standard of practice.

See 749

0
Based on clinical record reviews, review of facility policies and procedures and interviews, the facility failed to ensure that surgical equipment was disinfected in accordance with manufacturer's recommendations and/or the hospital failed to maintain a patient tracking mechanism for processed surgical equipment and/or that infection control practices in the operating room were followed in accordance with facility policy/standard of practice.

The findings include:

a. During tour of the operating suites in South Pavilion on 5/24/19 at 10:30am, it was observed that the facility utilized 3 Steris machines for high level disinfection of dilators used for anesthesia. Review of the log for daily checks failed indicate that daily quality checks were conducted in accordance with hospital policy and/or manufacturers recommendations. Steris machine #1 logs indicated that from 4/1/19-5/24/19 the machine read "fail" and/or the quality checks were not completed daily. CST#1 notified the Steris representative when the machine read "fail" to have it repaired. Steris machine #2 logs identified that from 4/1/19-5/20/19 daily quality checks were not completed daily. In addition, further observation identified that daily quality checks were last checked on 5/21/19 (3 days earlier) and a Dilator (utilized during anesthesia) was still in the machine. Steris machine #3 logs indicated that from 4/1/19-5/24/19, the quality checks were not completed daily.

Interview with Central Sterile Technician #1 on 5/24/19 identified that she didn't complete the quality check every morning in accordance with hospital policy. Interview with the Central Sterile Manager on 5/24/19 identified that she was not aware that the quality check for the 3 Steris machines was not completed every morning as directed and since the checks were not completed in accordance with hospital policy, could not ensure that the equipment was properly disinfected.

Review of hospital policy and manufacturers recommendations identified that the Steris machine is to run a Diagnostic cycle once every 24 hours to ensure that the instruments were disinfected thoroughly.

b. Review of the 3 Steris machine logs from 4/1/19-5/24/19 failed to indicate the hospital had a mechanism in place to track equipment to patients with each Steris load completed. Interview with the Central Sterile Manager on 5/24/19 at 11:30am identified that they did not track equipment processed in the 3 Steris machines. Subsequent to surveyor inquiry on 5/24/19, the hospital implemented a patient tracking log book for each of the 3 Steris machines.

The hospital failed to have a policy on how they track patients with surgical equipment that had been processed.

c. During tour of the operating suites in South Pavilion on 5/24/19, it was observed that trash in the scope room and dirty utility room was overflowing. Interview with the Nurse Manager on 5/24/19 identified that the trash should not have been overflowing and had not been emptied for a few days. Review of hospital policy identified that trash is to be removed from all areas daily.

d. During tour of the soiled utility room on 5/24/19, it was observed that clean supplies which included enzymatic cleaners, operating room canisters and manifolds were being stored in the soiled utility room. Interview with the Nurse Manager on 5/24/19 at 11:30am identified that clean supplies should not be stored in a soiled utility room.

e. During tour of the operating suites in South Pavilion on 5/24/19 at 10:30am, it was observed that a Surgical Resident with a beard walking into the restricted area without a hair covering. Interview with the Nurse Manager on 5/24/19 at 11:30am identified that the Surgical Resident should have had his/her beard covered prior to entering the restricted area. Review of hospital policy identified that all head and facial hair, including sideburns and hair at the nape of the neck, will be covered when in the semi-restricted and restricted areas of the surgical suites.

Based on clinical record reviews, review of facility policies and procedures and interviews, the facility failed to ensure that surgical equipment was disinfected in accordance with hospital policies and/or manufacturer's recommendations and/or the hospital failed to have a policy that directed to maintain a patient tracking mechanism for processed surgical equipment and/or that infection control policiesan/or practices in the operating room were followed in accordance with facility policy/standard of practice.


See A951

Based on clinical record reviews, review of facility policies and procedures and interviews, the facility failed to ensure that surgical equipment was disinfected in accordance with hospital policies and/or manufacturer's recommendations and/or the hospital failed to have a policy that directed to maintain a patient tracking mechanism for processed surgical equipment and/or that infection control policies an/or practices in the operating room were followed in accordance with facility policy/standard of practice.

The findings include:

a. During tour of the operating suites in South Pavilion on 5/24/19 at 10:30am, it was observed that in the 3 Steris machines daily quality checks were not monitored in accordance with hospital policy and/or manufacturers recommendations. Steris machine #1 logs indicated that from 4/1/19-5/24/19 the machine read fail and/or the quality checks were not completed daily. Steris machine #2 logs indicated that from 4/1/19-5/20/19 daily quality checks were not completed daily and/or indicated that they were not complete. In addition, further observation identified that daily quality checks were last checked on 5/21/19 (3 days earlier) and a Dilator was still in the machine. Steris machine #3 logs indicated that from 4/1/19-5/24/19, the quality checks were not completed daily.

Interview with Central Sterile Technician #1 on 5/24/19 identified that she didn't complete the quality check every morning in accordance with hospital policy. Interview with the Central Sterile Manager on 5/24/19 identified that she was not aware that the quality check for the 3 Steris machines was not completed every morning as directed and since the checks were not completed in accordance with hospital policy, could not ensure that the equipment was properly disinfected.

Review of hospital policy and manufacturers recommendations identified that the Steris machine is to run a Diagnostic cycle once every 24 hours to ensure that the instruments were disinfected thoroughly.

b. Review of the 3 Steris machine logs from 4/1/19-5/24/19 failed to indicate that the hospital had a mechanism in place to track patients with each Steris load completed. Interview with the Central Sterile Manager on 5/24/19 identified that they did not track equipment processed in the 3 Steris machines. Subsequent to surveyor inquiry, the hospital implemented a patient tracking log book for each of the 3 Steris machines.

The hospital failed to provide a policy on how they track patients with surgical equipment that had been processed.

c. During tour of the operating suites in South Pavilion on 5/24/19 at 1-:30am, it was observed that trash in the scope room and dirty utility room was overflowing. Interview with the Nurse Manager on 5/24/19 identified that the trash should not have been overflowing and had not been emptied in a few days. Review of hospital policy identified that trash is to be removed from all areas daily.

d. During tour of the soiled utility room on 5/24/19, it was observed that clean supplies which included enzymatic cleaners, operating room canisters and manifolds were being stored in the soiled utility room. Interview with the Nurse Manager on 5/24/19 identified that clean supplies should not be of been stored in a soiled utility room.

e. During tour of the operating suites in South Pavilion on 5/24/19 at 10:30am, it was observed that a Surgical Resident with a beard walking into the restricted area without a hair covering. Interview with the Nurse Manager on 5/24/19 at 11:30am identified that the Surgical Resident should have had his/her beard covered prior to entering the restricted area. Review of hospital policy identified that all head and facial hair, including sideburns and hair at the nape of the neck, will be covered when in the semi-restricted and restricted areas of the surgical suites.