HospitalInspections.org

Based on Quality Assurance Performance Improvement Plan review, Quality Committee meeting minutes review for July 2016 through April 2017, and interview, it was determined the facility failed to ensure a process was in place for Environmental Services (EVS), Lab, and Rehab Services QA (Quality Assurance) to be reported up to the Quality Committee and on to the Medical Staff and Governing Board. The failed practice did not ensure the Governing Board was responsible for all aspects of the Quality Program and created the likelihood to affect EVS, Lab, and Rehab Services. Findings follow.

A. Review of the Quality Assurance Performance Improvement Plan stated each department was to report QA findings to the Quality Committee on a quarterly basis.
B. Review of the Quality Committee meeting minutes for July 2016 through April 2017 revealed no QA was reported to the Quality Committee for EVS, Lab, or Rehab Services.
C. During an interview on 07/21/17 at 0845, the Assistant Director of Nursing confirmed there had been no QA reported for the above departments.

Based on review of the Biological Monitoring Log for Prospore2 and Prosure Mailer Biological Indicators, policy and procedure review and interview, it was determined the Infection Control Coordinator failed to ensure the time and temperature of the sterilization cycle was at a minimum of five minutes and 270 degrees Fahrenheit for six (two on 03/15/17, 04/14/17, 05/11/17, 06/02/17 and 07/13/17) of seven (01/31/17, two on 03/15/17, 04/14/17, 05/11/17, 06/02/17 and 07/13/17) cycles reviewed for 2017. The failed practice did not ensure the equipment being sterilized met the time and temperature requirements for sterilization and placed the patients at risk of infection from cross contamination. The failed practice had the potential to affect all patient on which the sterilized equipment was used. The findings follow:

A. Review of the Biological Monitoring Log for Prospore2 and Prosure Mailer Biological Indicators on 07/20/17 revealed there was no evidence of the time (minutes) or the temperature of the sterilization loads for two loads on 03/15/17 and one load on 04/14/17, 05/11/17, 06/02/17 and 07/13/17.
B. Review of the policy "Sterilization of Instruments" on 07/20/17 revealed "E. Operating the autoclave: Procedure: 2. Use the following parameters to sterilize pouches: 270* (degrees) F (Fahrenheit) (132* C (Celsius)) at 27.1 psi (pounds per square inch) and sterilize for 5 minutes; dry time is 30 minutes. F. Quality Control and Documentation: The following information is to be recorded and maintained for each sterilization cycle: 3. The exposure time and temperature, if not provided on the sterilizer recording chart."
C. The findings of A and B were confirmed in an interview with the Clinic Supervisor on 07/20/17 at 1410. She confirmed there were no printouts of the sterilization cycle from the sterilizer. She confirmed the time and temperature should have been documented on the Biological Monitoring Log for Prospore2 and Prosure Mailer Biological Indicators.


Based on interview, it was determined the Infection Control Coordinator failed to ensure the findings of the annual visit to the contracted linen company's receiving area for contaminated textiles were clearly separated from clean laundry areas and was maintained at a negative pressure compared with the clean areas of the laundry. The failed practice did not ensure laundry was handled to prevent the spread of infection and had the potential to affect all patients at the facility. The findings follow:

A. In an interview with the Director of Housekeeping on 07/20/17 at 0910, he stated he conducted visits to the contracted laundry service. A request was made for evidence of the visit. The Director of Housekeeping stated he did not keep documentation of the visit.
B. A request was made to the Assistant Director of Nursing for a policy regarding the visit to the contracted laundry service. In an interview with the Assistant Director of Nursing on 07/20/17 at 1520, he stated there was no policy regarding the visit to the contracted laundry service.


Based on observation and interview, it was determined the Infection Control Coordinator failed to ensure a sanitary environment in that chairs on four (5 Lower, 5 Upper, 6 Lower and 6 Upper Units) of nine (Unit A, Unit B, Unit C, Unit D, Unit E, 5 Lower, 5 Upper, 6 Lower and 6 Upper) patient care units had a buildup of dirt, food crumbs, pepper packets and/or pencils along the edges of the chair seat cushions. The failed practice promoted the spread of infection and had the potential to affect all patients on the 5 Lower, 5 Upper, 6 Lower and 6 Upper Units. The findings follow:

A. Observation of chairs on the 5 Upper Unit on the B Pod on 07/20/17 at 1310 revealed three chairs had a buildup of dirt, food crumbs and/or pepper packets and pencils along the edges of the seat cushions. The findings were confirmed in an interview with the Assistant Director of Nursing on 07/20/17 at 1310.
B. Observation of chairs on the 5 Lower Unit on the B and D Pods on 07/20/17 at 1315 revealed three chairs had a buildup of dirt and food crumbs along the edges of the seat cushions. The findings were confirmed in an interview with the Assistant Director of Nursing on 07/20/17 at 1315.
C. Observation of chairs on the 6 Lower Unit on the Landing Area on 07/20/17 at 1320 revealed six chairs had a buildup of dirt and food crumbs along the edges of the seat cushions. The findings were confirmed in an interview with the Assistant Director of Nursing on 07/20/17 at 1320.
D. Observation of chairs on the 6 Upper Unit on the D Pod on 07/20/17 at 1325 revealed three chairs had a buildup of dirt and food crumbs along the edges of the seat cushions. The findings were confirmed in an interview with the Assistant Director of Nursing on 07/20/17 at 1325.