HospitalInspections.org

Based on observation, staff interview, and document review the facility failed to ensure the confidentiality of each patient's medical record. This deficient practice had the potential to allow unauthorized access to patient's private medical information.

Findings include:

- Observation in the Intensive Care Unit on 10/12/2016 at 8:30 AM revealed Patient # 7's medical record open and unattended at the computer charting station next to room # 7.

Intensive Care Unit Manager Staff B interviewed on 10/12/2016 at 8:30 AM indicated medical records should not be left open and unattended at the computer charting stations.

Policy reviewed on 10/13/2016 at 2:30 PM directed "...Employees who have access to confidential information via electronic or paper records must safeguard this information..."

Based on observation, staff interview, and document review the facility failed to ensure staff securely stored medications. This deficient practice had the potential to allow unauthorized persons access to patient medications.

Findings include:

- Observation in the Intensive Care Unit on 10/12/2016 between 8:30 AM and 9:15 AM revealed Registered Nurse Staff J removing medications from the Pyxis machine (computer medication dispensing machine) for Patient # 6. Staff J with an unidentified college student proceeded to a computer charting station outside Patient #4's room (Room #11). Staff J indicated Patient #4 was feeling nauseated so they would be waiting to administer most of the scheduled medications removed from the Pyxis. Staff J left the following medications unattended at the computer charting station; 2 Capsules of Docusate Sodium 100 milligrams (a stool softener), One Famotidine 20 milligram tablet (an acid reducing medication), One vial of Furosemide 20 milligram/2milliter (a medication used to decrease fluid in the body), Two tablets of Mucinex 600 milligrams (a medication used to loosen mucus), One vial of Toradol 15milligrams/1 milliliter (a medication used to treat pain), 0ne tablet of Metoprolol 12.5 milligrams (a medication used to regulate blood pressure), One package of Miralax 17 grams (a medication used to relieve constipation), One tablet of Senokot 8.6 milligrams ( a stool softener), Four tablets of Effxor 37.5 milligrams ( a medication used to treat depression).

Registered Nurse Staff J interviewed on 10/12/2016 at 1:30 PM indicated they had set the medications at the computer charting station because they were working with two college nursing students and two different patients at the same time and did not want to get the medications mixed up. Staff J indicated they had pulled the medications for Patient #4 but discovered they were nauseated so s/he did not want to administer pill form medications at that time.

Intensive Care Unit Nurse Manager Staff B interviewed on 10/12/2016 at 9:05 AM revealed leaving medications unsecured was a practice on the unit and stated, "We will improve this process".

Policy titled "Medication Storage" reviewed on 10/13/2016 at 1:55 PM directed "... All drugs and biologicals must be stored in a manner to prevent access by non-authorized individuals ..."
.

Based on observation, staff interview, and policy review the facility failed to ensure all expired and non-useable medications were removed from patient care areas and unavailable for patient use in the Intensive Care Unit and the Intermediate Care unit. This failure had the potential to expose patients to ineffective medications that could cause a worsening of condition.

Findings include:

- Observation in the Intensive Care Unit on 10/12/2016 at 8:30 AM revealed two 500 milliliter bags of 5% Dextrose (a medication used to provide fluid maintenance and sugar) with an expiration date of 9/2016.

Intensive Care Unit Nurse Manager Staff B interviewed on 10/12/2016 at 8:30 AM verified the dates on the expired medication.

- Intermediate Care Unit's medication refrigerator observed on 10/12/2016 at 3:40 PM revealed an open and punctured vial of Tuberculin undated and available for use.

Registered Nurse Staff I interviewed on 10/12/2016 at 3:50 PM acknowledged the open and undated vial of Tuberculin and stated, "all multi dose medications are required to be dated".

Policy titled "Multi-Dose Vials" reviewed on 10/13/2016 at 1:00 PM directed "...With initial withdrawal, note on the vial label date, time, and expiration date ... and ... Discard the outdated or undated multi-dose vial".

Based on observation, interview and policy review, the Dietary Manager failed to ensure maintanence of a clean food preparation environment and failed to ensure kitchen area cleanliness. This deficient practice had the potential to expose all patients and healthcare workers to food contamination and unclean environment.

Findings include:

- Observation on 10/12/16 at 8:15 AM in one of two kitchen storage rooms revealed one open rack with clean cooking utensils, storage bowls, lids, and cloth napkins stored next to a mop bucket fill sink with floor drain.

Interview with Food Service Manager Staff Z confirmed the clean utensils are stored next to the mop bucket fill sink. S/He stated "we are so limited on space there is just no place else to store them. We only fill the bucket here. When the bucket is emptied it is emptied into the floor drain under the sanitation sinks."

- Observation on 10/13/16 at 12:45 PM revealed a washable cover had been placed over the mop bucket fill sink and drain.

- Observation on 10/12/16 at 8:15 AM at the fresh produce preparation sink revealed the sink was located next to the hand washing sink without a barrier between the sinks.

Interview with Administrator Staff A confirmed the Hospital does not have a barrier between the produce preparation sink and the handwashing sink. "I have actually tried to get rid of that sink in the past, but we could not figure out a better place to put it".

- Observation on 10/13/16 at 12:45 PM revealed a splash guard had been put up between the produce preparation sink and the handwashing sink.

- Observation on 10/12/16 at 8:15 AM in the Kitchen revealed the heating and cooling vents in the ceiling with visible dust and debris on all surfaces.

Policy review on 10/13/16 at 10:45 AM revealed facility failed to develop a policy for kitchen cleaning to include ceiling heating and air vents.

Review of the LaTour Contract, the contracted dietary provider, directed the "...the kitchen areas will be cleaned daily by Harvest Grill. All other areas of the dining center to be cleaned are the responsibility of Hospital... ...shall maintain consistently high standards of sanitation, service, safety and infection control throughout the food service facilities..."

Interview with Food Service Manager Staff Z acknowledged the " kitchen staff are responsible for cleaning daily and as needed between times. Grill vents are cleaned and scrubbed daily, floors are swept and cleaned daily. We do not clean the ceiling heat and air vents."

Based on observation, staff interview and policy review the facility failed to ensure staff and patient safety by ensuring the generator was tested for a minimum of 30 minutes monthly, and a remote safety stop station was available. The facility failed to ensure all oxygen cylinders were secured in such a way as to prevent them from falling in one of four observed radiology rooms. These failures had the potential to cause the back up generator not to work in case of an emergency situation or injury to patients or staff.

Findings include:

Generator test log book reviewed on 10/12/2016 at 11:00 AM revealed from January 2016 through September 2016 month checks were performed for less than 30 minutes.

January 2016 - September 2016 the generator logbook documentation indicated testing from " 8:00 AM - 8:15 AM " .

Maintenance Staff KK interviewed on 10/13/2016 at 9:45 AM indicated monthly generator checks are performed for only 15 minutes each month. Staff KK verified the entries in the logbook.

NFPA 110(99), Sec. 6-4.2; NFPA 110(02), Sec. 8.4.2 reviewed on 10/13/2016 at 11:45 AM revealed that generators must be exercised under a load for a minimum of 30 minutes every month.



- Maintenance Room observed on 10/12/2016 at 11:45 AM revealed no remote manual stop stations outside the room the generator is located.


Maintenance Staff LL and Staff LL interviewed on 10/12/2016 at 11:45 AM verified they could not locate a remote manual stop station for the generator.

NFPA 110, 5.6.5.6 regulation reviewed on 10/13/2016 at 12:15 PM states: "All installations shall have a remote manual stop station of a type to prevent inadvertent or unintentional operation located outside the room housing the prime mover, where so installed, or elsewhere on the premises where the prime mover is located outside the building." An appendix item at A-5.6.5.6 suggests: "For systems located outdoors, the manual shutdown should be located external to the weatherproof enclosure and should be appropriately identified."

- Ultra Sound Exam Room observed on 10/11/2016 at 1:20 PM revealed one unsecured oxygen cylinder near the end of the bed.

Radiology Director Staff V interviewed on 10/11/2016 at 1:20 PM indicated the tank was in the room because sometimes out patients do not bring a large enough tank from home and so the staff will let them use the facilities oxygen. Staff V indicated they did not know the oxygen cylinder was required to be in a cart or otherwise secured and stated, "We will fix that right away".

Policy titled Distribution and storage of Compressed Gas Cylinders reviewed on 10/13/2016 at 11:30 AM directed "...Cylinders of oxygen and nitrous oxide will be secured in a self-contained cart..."

The Hospital reported a census of 42 patients. Based on observation, interview and policy review, storage of supplies were not kept below 18" from the ceiling; the facility failed to test all equipment to ensure it was in working condition for 10 of 10 observed fire extinguishers located throughout the building, the facility failed to test the facilities generator for a minimum of 30 minutes monthly and failed to ensure supplies available for patient use in 1 of 3 operating rooms (#1), one of six anesthesia carts (#1), anesthesia room supply area, three of five emergency supply carts (telemmetry unit, treatment unit and intermediate care unit.

This deficient practice put all patients, visitors, and employees at risk of danger from fire and ineffective treatments and medicines.

Findings Include:

- Tour of the Facility of 10/10/2016 at 11:15 AM revealed 10 fire extinguishers distributed throughout the facilities patient care areas to include the Telemetry Unit, Immediate Care Unit, Intensive Care Unit, connecting hallways with a tag identifying the last maintenance check was performed on 7/24/2016.

Maintenance Staff LL interviewed on 10/12/2015 at 11:30 AM indicated the " painter " is responsible for the fire extinguisher checks and they were unaware they had not been checked since July 2016.

- Observation on 10/12/2016 at 4:15 PM the Fire extinguisher in the Operating Room hallway showed no indication of monthly checks being logged.

OR manager, Staff S interviewed on 10/12/2016 at 4:30 PM and revealed she was not aware that the fire extinguisher was not being checked monthly. Stated she will notify the company that does them to make sure it doesn ' t get missed again.

Occupational Safety and Health Administration (OSHA) requires that
portable extinguishers ... shall be visually inspected monthly. [29CFR1910.157(e)(2)]

- Observation on 10/11/16 at 1:30 PM revealed boxes in the materials supply storage were closer than 18" to the ceiling. The presence of two sprinkler heads were noted.

Interview with Materials Coordinator Staff Q acknowledged the boxes were higher than the maximum allowed height.

Observation on 10/12/16 at 9:00 AM revealed the boxes had been moved and all items in the room were stored lower than the maximum height.

Review of the Kansas Fire Code reveals that facilities are to "ensure that all storage is kept at least 18 inches below/away from sprinkler heads."

- Occupational Safety and Health Administration (OSHA) and the National Fire Protection Association (NFPA) require that shelves and stacked materials not exceed the height of 18 inches below sprinkler heads [29CFR1910.37(a)(4); 29CFR1910.159(c)(10); NFPA 101, §9.7.1.1, §9.7.1.4, and §9.7.5; NFPA 13, §8.6.6; NFPA 25, §2-2.1.2]

- Operating Room #1, red tool cabinet, observed on 10/12/2016 at 3:30 PM revealed the following expired supplies:

1. Intralock 3 way transparent stopcock, with expiration date of 4/2016.

- Profusion/Anesthesia Room observed on 10/12/2016 at 3:55 PM revealed the following expired supplies:

1. Suction tubing was out of sterile wrapper in anesthesia cart #1.
2. Manifold Baseplate check valve with an expiration date 09/2016 in anesthesia cart # 1.
3. Opened package of Red Dot 3M EKG pads with an expired date of 11/2015.
4. Glidewire count of 3 with an expiration date of 01/2016.

Operating room manager Staff S interviewed on 10/12/2016 at 4:20 PM acknowledged the outdated operating room supply items, and revealed that the other supplies are to be checked by other departments and they follow up with them about their expired supplies.

- Telemetry Unit ' s emergency supply cart observed on 10/11/2016 at 2:50 PM revealed a package of 4x4 gauze pads with an expiration date of 4/2013.


Telemetry Unit Nurse Manager Staff C interviewed on 10/11/2016 at 2:50 PM acknowledged the expiration dates of the package of gauze pads.


- Treatment Room ' s emergency supply cart observed on 10/11/2016 at 3:00 PM revealed a package of 4x4 gauze pads with an expiration date of 4/2013.


Admissions Clerk Staff NN interviewed on 10/11/2016 at 3:15 PM acknowledged the expired supply and stated, " I will call respiratory therapy right now to let them know " .


- Intermediate Care Unit ' s emergency supply cart observed on 10/11/2016 at 3:40 PM revealed four tongue depressors with an expiration date of 3/2016.


Intermediate Care Unit Nurse Manager Staff C interviewed on 10/11/2016 at 3:40 PM acknowledged the expiration dates of the four tongue depressors.


- Intermediate Care Unit observed on 10/11/2016 at 3:45 PM revealed a supply area with one package of TED anti embolism stockings (stockings worn to decrease the risk of blood clots in the legs) with an expiration date of 6/2016 and a box containing 16 sterile gloves size 7 with an expiration date 12/2011.


Registered Nurse Staff I interviewed on 10/11/2016 at 3:50 PM verified the dates of the expired TED anti embolism stockings and the box of sterile gloves.


Intensive Care Unit Nurse Manager Staff B interviewed on 10/12/2016 at 8:35 AM revealed Respiratory Therapy Department is responsible for the monthly emergency supply cart checks.


Policy titled, " Equipment and Routine supplies, " reviewed on 10/13/2016 directed staff that " ...supplies will be checked periodically to assure outdated supplies are removed from the patient care areas ... "

Based on observation, interview, and policy review, the infection control officer failed to assure an effective on going infection control program that identified potential environmental infection control risks by: failing to ensure staff compliance with handwashing; failing to provide monitoring and interventions of hand hygiene before and after glove use; failing to provide a clean environment in the food preparation area; failing to ensure an environment free of pests; failing to ensure staff completed required tasks during a terminal clean of a patient's room; failing to ensure staff had access to personal protective equipment where needed; and failing to ensure facility cleanliness in all areas of the facility including the surgical suites (Refer to A-0749).

The cumulative effect of these deficient practices had the potential to expose all patients and healthcare workers to infectious diseases.

Based on observation, interview, and policy review, the infection control officer failed to assure an effective on going infection control program that identified potential environmental infection control risks. The hospital failed to ensure staff compliance with handwashing in the intermediate intensive care unit, failed to provide monitoring and interventions of hand hygiene before and after glove use, failed to provide clean environment in the food preparation area without potential of contamination, failed to ensure an environment free of pests, failed to ensure staff handled dirty linens to avoid potential contamination, failed to ensure staff completed required terminal clean of patient room and in one of the three suites (suite #1) , failed to ensure staff adequately cleaned an operating room (OR) between surgeries, failed to ensure staff had access to personal protective equipment, failed to develop an active infection control system to identify, report, investigate, monitor and implement infection control practices for one of one observed area in the central sterile processing decontamination area, and failed to ensure facility cleanliness in all areas. These deficient practices had the potential to expose all patients and healthcare workers to infectious diseases.

Findings Include:

- Observation on 10/11/16 at 9:00 AM in the central supply storage room revealed dust accumulated on all surfaces of the heating and cooling vent and dust and debris on all floor surfaces including under the storage racks.

Interview with materials coordinator Staff Q confirmed the area had evidence of dust and debris and "no one in housekeeping is scheduled to clean in here, we should be responsible for this."

- Observation 10/11/2016 at 3:35 PM in the Intermediate Care Unit revealed Housekeeping Staff L dragging two blue plastic bags full of dirty linens across the floor and down the hallway to their cart that was sitting outside the unit's entrance.

Intermediate Care Unit Nurse Manager Staff C interviewed on 10/11/2016 at 3:45 PM acknowledged the housekeeping staff should not have dragged the bags through the unit.

Infection control Officer Staff O interviewed on 10/11/2016 at 4:00 PM agreed the housekeeping staff should not drag bags of dirty linens on the floor and stated they are included in the infection control audits, but that behavior had not been observed.

- Policy titled Processing Soiled Linen reviewed on 10/12/2016 at 4:30 PM directed "...All soiled linen should be handled on such a manner that prevents contamination..."

- Intermediate Care Area observed on 10/11/2016 at 3:40 PM revealed a refrigerator with patient and staff food items stored together.

Intermediate Care Unit Manager Staff C interviewed at 3:45 PM acknowledged staff food is also stored in the refrigerator, but only on the bottom and not on the same shelves as patient food.

Administrative Staff A interviewed on 10/13/2016 at 8:05 AM indicated they have always had patient and staff food in the same refrigerator, but they have been separated by labeled shelving which is patient food and which is staff food.

- Policy titled Refrigerator Monitoring/Cleaning reviewed on 10/12/2016 at 4:50 PM directed "...No personal employee food may be kept in the patient nourishment refrigerator..."

- Observation on 10/12/16 at 8:15 AM in one of two kitchen storage rooms revealed one open rack with clean cooking utensils, storage bowls, lids, and cloth napkins stored next to a mop bucket fill sink with floor drain.

Interview with Food Service Manager Staff Z confirmed the clean utensils are stored next to the mop bucket fill sink. S/He stated "we are so limited on space there is just no place else to store them. We only fill the bucket here. When the bucket is emptied it is emptied into the floor drain under the sanitation sinks."

- Observation on 10/12/16 at 8:15 AM at the fresh produce preparation sink revealed the sink was located next to the hand washing sink without a barrier between the sinks.

Interview with Administrator Staff A confirmed the Hospital does not have a barrier between the produce preparation sink and the handwashing sink. "I have actually tried to get rid of that sink in the past, but we could not figure out a better place to put it".

- Observation on 10/12/16 at 8:15 AM in the Kitchen revealed the heating and cooling vents in the ceiling with visible dust and debris on all surfaces.

- Policy review on 10/13/16 at 10:45 AM revealed facility failed to develop a policy for kitchen cleaning to include ceiling heating and air vents.

- Review of the LaTour Contract, the contracted dietary provider, directed the "...the kitchen areas will be cleaned daily by Harvest Grill. All other areas of the dining center to be cleaned are the responsibility of Hospital... ...shall maintain consistently high standards of sanitation, service, safety and infection control throughout the food service facilities..."

Interview with Food Service Manager Staff Z acknowledged the "kitchen staff are responsible for cleaning daily and as needed between times. Grill vents are cleaned and scrubbed daily, floors are swept and cleaned daily. We do not clean the ceiling heat and air vents."

- Observation on 10/12/16 at 8:45 AM in the cafeteria dining room revealed the presence of dust and bugs along 4 of 4 window sills.

Interview with Food Service Manager Staff Z confirmed the cafeteria dining room is cleaned by environmental services, not the kitchen staff.

Interview with Environmental Management Services District Manager Staff AA and Supervisor Staff BB confirmed the presence of the dust and bugs along the window seals.

- Observation on 10/12/16 at 11:15 AM of terminal cleaning by unidentified housekeeping staff of patient room 117 revealed they did not wipe the bed frame under mattress completely to the center, did not wipe all surfaces of bed including raising the bed and wiping the underframe, wall elements at the head of the bed, or all surfaces of the recliner, and laid contaminated pillows on the cleaned mattress surface, cleaned them and laid them on the un-cleaned counter surface.

- Policy review on 10/13/16 at 10:45 AM of "Cleaning of Nursing Units" revealed "...steps should be followed to finish cleaning for the patient room: wipe mattress, headboard, footboard, rails, base, cords and pillow. Use small brush for areas on the bed underneath the mattress at the foot and o the bed rails, etc. ...wipe pillow and phone inside and out, open and clean both sides of bed table using brush on rails to remove any crumbs, wipe mirror, top, and base, clean furniture cushions, frame and lift base of reclining chair to clean, wipe closet inside and out and dust lower inside drawer...move furniture and scrape all corners and edges with grout brush or floor scraper to remove any build up in corners..."

Interview with Environmental Management Services District Manager Staff AA and Supervisor Staff BB acknowledged the areas that were not cleaned.

- Observation on 10/12/16 at 11:30 AM in the intermediate intensive care unit bay 7 revealed RN Staff DD wearing gloves, filling blood specimen tubes, placing the tubes into the laboratory specimen bag, and carrying the bag to the laboratory without removing the gloves. EKG Technician Staff EE was observed wearing gloves, performing the EKG, cleaning the machine, storing the machine, and entering another patient bay while removing the gloves without handwashing.

- Review of policy titled "Universal Precautions" directed "...gloves must be changed between patients and after each task is completed if going from "dirty" procedures to "clean" procedures on the same patient;... ...hands are to be washed after removal of gloves ... ...use of gloves in a non-patient area such as the hall or nursing stations is only indicated when performing a task that may involve contact with blood or body fluids/substances..."

Interview with Infection Control Staff O acknowledged "handwashing is an ongoing issue that we are constantly monitoring as part of the quality indicators. We have shown with our quality reports that compliance has trended down and we are employing new techniques for monitoring such as the secret shopper approach to monitoring."

- Observation of Staff K in the Intensive Care Unit (ICU) on 10/12/2016 at 8:20 AM providing suctioning for Patient #4 who is currently on a ventilator. Staff K stated to the patient prior to deploying the suctioning tube "this is going to make you cough a little". Patient #4 began coughing during the procedure. Staff K failed to wear the mask provided in the suctioning kit or goggles that are located in the room while performing the suctioning procedure.

- Observation in Operating Room # 3 on 10/12/2016 at 8:48 AM while patient #15 was being moved from the OR table to a cart when x-ray technician staff GG touched patient without having gloves on in helping with transfer.

Interview with X-ray technician staff GG on 10/12/2016 at 8:50 AM s/he stated, "I had just removed my gloves and patient started moving and had to put my hands on him".

Interview with ICU Nurse Manager Staff B on 10/13/2016 at 7:55 AM acknowledged that the Ballard's ventilator suction system is a closed system which reduces the potential for contamination. Staff B indicated they staff should still always wear gloves, but if the patient is coughing staff should also be wearing masks and goggles.

- Review of policy titled "Suctioning" on 10/12/2016 at 5:10 PM directed "...Suctioning of an artificial airway is a sterile procedure and sterile techniques must be followed. Universal precautions will be followed in regards to mask, gloves, gowns...

- Soiled Utility Room observed on 10/12/2016 at 8:30 AM revealed a hopper (flushable basin) without a splashguard. The facility failed to ensure personal protective equipment (PPE) such as gowns, masks, or face shields were readily available to prevent contamination during disposal of potential bio hazardous materials.

ICU Nurse Manager Staff B interviewed on 10/12/2016 at 8:30 AM indicated the ICU staff rarely uses the hopper, but the telemetry unit does. Staff B acknowledged other than gloves there are no immediately available PPE items located in the room.

- Policy titled "Universal Precautions" reviewed on 10/13/2016 at 9:50 AM directed "... Personal protective equipment will be placed in convenient locations throughout the hospital...and ...Masks in combination with eye wear (goggles or glasses with solid side shields) or chin length face shields should be worn during procedures that are likely to generate splattering of blood or other body fluids to prevent exposure of mucous membrane of the mouth, nose, and eyes. (i.e. endotracheal intubation, suctioning, bronchoscopy, or endoscopy)..."

- Observation in Operating Room #2, CRNA staff JJ, on 10/12/2016 at 9:33 AM, touched sharps container and trash can without gloves on and did not sanitize hands, then donned clean gloves.

Surgical manager, Staff S interviewed on 10/12/2016 at 10:05 AM and stated that hand hygiene should be practiced the same by all staff, and alcohol gel should be on the anesthesia cart to use when changing gloves, there was no hand sanitizer available on the anesthesia cart.

- Observation on 10/12/2016 at 9:19 AM in OR #2 revealed a blood smear on the foot rest of surgeon's stool.

Interview with CRNA staff JJ confirmed this was the second surgery of the day and the room had been cleaned prior to this surgery.

Circulating nurse RN staff MM interviewed on 10/12/2016 at 9:50 AM stated, "Oh dear."

- Observation of terminal cleaning of Operating Room (OR) #1 on 10/12/2016 at 12:00 PM revealed housekeeping staff II did not move the surgical table from its original position for the entire cleaning of the room and paper was noted under this table and an IV cap under the anesthesia table. Housekeeping staff II did not flip the surgical table mattress to clean the underside of the mattress or the base of bed.

- Observation of terminal cleaning of Operating room #1 on 10/12/2016 at 12:25 PM observed revealed housekeeping staff II cleaned the ceiling light covers and remainder of the ceiling after all the walls were cleaned. Housekeeping staff II did not clean a window and the stainless steel pillar in the OR room.

- Observation of terminal cleaning of operating room #1 on 10/12/2016 at 12:35 PM revealed housekeeping staff II did not clean wall mounted TV hanging down on the left side of the surgery suite with a speaker suspended from the left corner of the surgical suite. The surgical light armature above the surgery table were not cleaned to the ceiling only wiped down the back side of the 3 surgery lights and as far up the arm as this person could reach.

Housekeeping staff II interviewed on 10/12/2016 at approximately 1:00 PM, stated he was not trained to clean the window or the stainless column, stated that another cleaning staff will come in and clean that after this cleaning due to special cleaning solution is used on the stainless steel column and window. They also stated they could not reach the top of the lighting armature above the surgical table, and was not taught to clean the mounted TV or speaker hanging from the ceiling.

- Policy titled, "Terminal Cleaning for OR and Heart Catheterization Labs," reviewed on 10/14/2016 directed staff that "...in a counter clockwise direction: disinfect with Oxyfect H, all objects and wall starting high and working down the wall. Do not forget stainless steel return air vents." And clean mattress, flip mattress then clean again, clean under mattress table, base of bed, rails, foot pedal, and controls for bed..."


- Observation of the "Steris Record Sheet " on 10/12/2016 at 11:00 AM revealed the one of two staff failed to document the results of test and control vials.


- Review of the record sheet revealed staff failed to document the results of test and control vial results on the following dates: 9/26/16 at 7:15AM, 8/29/16 at 1:30 PM, 8/29/16 at 7:40AM, 8/8/16 at 7:20AM, 8/8/16 at 7:55AM, 8/1/16 at 7:15AM, 8/1/16 at 7:35AM, 7/25/16 at 8:20AM, 7/25/16 at 7:30AM, 7/11/16 at 8:20AM, 7/11/16 at 7:30AM, 6/27/16 at at7:20AM, 5/31/16 at 8:25AM, 5/31/16 at 7:35AM, 5/9/16 at7:45AM, 2/2/16 at12:15PM.


Central Processing RN Staff HH interviewed on 10/12/2016 and revealed that she was not aware that the results to the Test and Control Vials were not documented appropriately in the log book.

Policy titled, "Sterilization- Performance Record and Biological Monitoring," reviewed on 10/13/2016 at 1:45 PM directed "...results are recorded after 24 Hours..."

.