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Based on staff interview and review of medical records, and root cause analysis reports, the facility failed to ensure resources related to adequate number of sterile processing personnel, and surgical instrument availability for scheduled surgeries were consistently provided to meet surgical service needs. This failure affected 4 of 4 sample patients (#4, #5, #6, #7) who were potentially exposed to contaminated surgical instruments due to lack of staff assigned sterile processing duties. In addition, 1 of 1 sample patient (#7) was anesthetized for 34 minutes prior to surgery because an appropriately cleaned and sterilized instrument tray was not readily available for use. The findings were:

1. Review of the medical record revealed surgeon #1 performed surgery for patient #4 on 6/3/16. Further review revealed the surgeon placed an instrument for suctioning in the surgery area and the instrument did not function properly due to clogged dried blood in the small lumens. A replacement instrument was checked prior to use and dried blood was found on this instrument too. A third instrument was used to complete the surgery. Review of the root cause analysis revealed the instruments were not properly cleaned and inspected.

2. Review of the medical record revealed surgeon #2 performed orthopedic surgery for patient #5 on 7/19/16. Interview with the surgeon on 10/18/16 at 7:50 AM revealed the procedure required use of an instrument called an acetabulum reamer. He stated the instrument was brought to the OR as available for use, but upon inspection had "bone-like fragments."

3. Review of the medical record revealed surgeon #1 performed surgery for patient #6 on 9/13/16. This review revealed the surgeon placed a microlarygeal suction in the patient's throat and withdrew it due to malfunction. At that time an inspection of the interior areas of the instrument revealed dried bloody materials. Interview with certified surgery technician #1 on 10/17/16 at 3:10 PM revealed the instruments had been washed, cleaned, inspected, and stored in the clean instrument room on the Friday before the scheduled surgery on Tuesday. She further stated on Monday morning the instruments were packaged and sterilized without an additional inspection or cleaning. Review of the root cause analysis revealed the surgery sets were not properly examined in the OR prior to use because one sterile processing staff was reassigned other duties before he was able to complete the process.

4. Review of the assistant CNO's 10/19/16 documentation of the events that occurred after patient #7 was wheeled into the OR on 10/19/16 revealed the surgical instrument table was prepared with contaminated instruments. Interview with surgeon #2 on 10/19/16 at 9:20 AM revealed he insisted that all instruments be removed and he was informed that the only other instrument pack for the procedure was not available. The second instrument pack had to be flash sterilized for timeliness, which caused a 34 minute delay in the procedure while the patient remained under general anesthesia. The surgeon stated the second instrument pack was not available because the hospital had only one full-time employee in the sterile processing department at the Lander location. He further stated that one employee responsible for sterile processing was inadequate and he had stated this to administration in the past.

5. Interview on 10/19/16 at 9:45 AM with the Lander assistant CNO and the ICP confirmed the issues with sterile processing that surgeon #2 shared with the surveyors had occurred. The assistant CNO said she was not sure of the cause. She also stated the hospital had been attempting to hire another staff member in the sterile processing department at the Lander location without success, and some travel staff with experience in that area sometimes helped out.

6. Interview on 10/28/16 at 8:30 AM with the interim director of peri-operative services revealed the facility's standard was to prepare instrument trays the night before a scheduled surgery and utilize "count sheets" to ensure all necessary instruments and items were available for surgery. She further stated this process required staff to ensure a back-up set was readily available for use, but this standard was not followed on 10/19/16 when the only available replacement instruments had not been sterilized. The interim director of peri-operative services also stated that a written policy and procedure that addressed ensuring necessary surgical instruments were available at the time of scheduled surgeries had not been developed.

Based on observation, interview with staff, review of medical records, root cause analysis reports, procedure standards, compliance monitoring records, temperature and humidity logs, and temperature and humidity monitoring instructions, the facility failed to utilize the quality assessment and performance improvement process to ensure ongoing compliance related to infection control and the proper processing of surgical instruments and safe injection practices; as well as maintaining humidity in ORs, the sub-sterile room, and endoscopy rooms within an acceptable range (A308). The cumulative effect of the deficient practice resulted in a determination that the hospital failed to meet the Condition of Participation for Quality Assessment and Performance Improvement.