HospitalInspections.org

Based on observation and interview, the hospital failed to maintain an ongoing infection control program that includes active surveillance, early detection, control, and education consistent with nationally recognized infection control practices or guidelines.

These failed practices had the potential to create an ineffective infection control program and increased the infection control risk to the hospital's inpatients and outpatients.

Finding:

1. Unwrapped laryngoscopes were observed on top of the crash cart in the emergency department. There was no indication the laryngoscopes were cleaned prior to placement on the cart.

Staff A (08/07/19 at 9:35 am) stated disposable laryngoscopes should be used.

2. Boxes of medical records were observed stored in the basement; boxes were sitting directly on the floor, multiple ceiling tiles were missing exposing sewer and water pipes directly over the medical records.

Staff O (08/07/19 at 9:30 am) was unaware of process for replacing ceiling tiles.

3. Staff K and Staff L (Housekeeping staff) were observed changing the red bag trash in the public hallway from an isolation room. Staff K was observed gowning and gloving (no hand hygiene was performed), entered the isolation room, removed the trash and brought the trash into the hallway fully gowned and gloved. After gown and gloves were removed, no hand hygiene was performed.

Staff K (08/07/19 at 9:45am) stated on the job training was provided to staff on how to use Personal Protective Equipment (PPE), how to clean rooms and remove trash.

4. The Operating Rooms (ORs) were being converted from ORs to Materials Management. OR lights had been removed from the ceiling and were lying on the floor, dust and equipment were scattered throughout the rooms. An ICRA (Infection Control Risk Assessment) was not posted to indicate any assessment for containment of dust/construction debris had been performed to prevent contamination to patients. Corrugated boxes were brought directly into the storage area and used to store hospital supplies. Linens used for patients were in an open hallway; the linens were covered with a non-intact cover. A "sterile" OB pack used for emergency care in the emergency room was located in an uncovered/unmonitored/unclean construction area.

Staff A (08/08/19 at 11:15 am) stated the ICP was new in the position, was receiving training from the corporate ICP and would be attending an APIC (Association for Professionals in Infection Control and Epidemiology) course. Staff P (08/09/19 at 10:00 am) stated she/he was in the process of removing all corrugated boxes from the area.