HospitalInspections.org

32870



Based on observation and interview it was determined that the facility failed to follow and complete it's own plan of correction from the 4/20/2016 Medicare recertification survey.

Findings were:
On the 6/01/2016 follow up survey, observation in the trauma room revealed that there were still reusable surgical instruments available for use by staff. These surgical instruments were found in an open top bin located on a supply cart and could potentially have been used by staff. There were approximately 18 instruments in peel packs with what appeared to be a sterilization date written in black marker on the bottom of each peel pack. The dates on these peel packs included: 4/11/12, 5/28/12, 6/22/12, 8/7/12, 8/8/12, 3/15/13, 4/24/13, 11/22/13, 6/18/14, 9/3/14, 8/31/15, 8/27/15, 12/17/15. Also found were two surgical towels found with the date of 8/20/15 written on each of the peel packs. Four curved surgical hemostats and one toenail clipper were also found , each instrument was in its own peel pack with no sterilization date found on the packaging. Additionally there were wrapped reusable bowls found with sterilization dates on the packaging to include: 3/30/2015, 3/26/15, 5/26/14 and 4/13/16. All of these reusable items were found to have sterilization dates which were prior to the 4/20/2016 Medicare recertification survey. The facility's own plan of correction written for the deficiency cited during the 4/20/2016 survey stated: "The Hospital Administrator has made the decision to discontinue in house sterilization due to the fact that it is seldom required. All reusable items will be replaced with single use, disposal, sterile items. The Autoclave in the facility on the dates the survey has been disposed of." In an interview with the Chief Executive Officer, Chief Nursing Officer and Quality Assurance Director on 06/01/2016 it was confirmed that the instruments found by the surveyor in the trauma room were available for use had been in the facility during the 4/20/2016 survey and had not been removed and replaced with single use instruments as the facility plan of correction, dated 5/9/16 had indicated.