HospitalInspections.org

21204

Based on observation and staff interview, the hospital did not maintain the condition of the physical plant and the overall hospital environment in such a manner that the safety and well-being of patients are assured.


Findings include:

During a tour of the 4th floor Bernstein Pavilion building on the afternoon of 7/1/2015, the following were identified and brought to the attention of the Director of Engineering who promised to correct the deficiencies.
The following observations were noted during tour of the Psychiatric Unit:
1- The handle and a padlock on the refrigerator at the dining room represented risk for looping.
2- The electric wiring and the copper water coils behind the ice machine were not secure and impose a risk of looping.
3- There were many small drain flies observed in different areas of the Psychiatric Unit.
4- The handrails in the shower room next to the dining area were short and not completed from wall to wall, therefore, these handrails represent a looping risk.
5- The handrails inside all the bathrooms were not extended from wall to wall and being short, they impose a risk for looping.
6- The bulletin board on the wall of the corridor was not secured properly and had gaps around it, which impose a looping risk.
7- The rails of the handicapped shower imposed a looping risk.
8- The lips of the strike plates of all the doors frames were observed to be protruded metals and impose safety risk.



26934

Based on observation, review of documents, and staff interview, the facility failed to: 1) ensure that the sterilization of surgical equipment were performed and recorded by staff in accordance with CDC recommendations and AAMI standards, and 2) failed to implement safe infection control practices to reduce the risk of patient infection.


Findings include:


1. During the tour of the Brooklyn Campus Operating Room Suite on 07/03/15 at approximately 11:00AM, it was noted that the facility was using one 100S sterrad (low temperature sterilizer) to sterilize surgical instruments. Review of the sterilization records revealed that the facility did not consistently perform and record the test results of the biological indicator on a daily basis as recommended by CDC under "Guidelines for Disinfection and Sterilization in Health-Care Facilities."

For example: Review of the sterilization records for the month of June, 2015 for loads sterilized by the 100S Sterilizer, it was noted that the facility did not perform and read the test results of the Biological Indicator (BI) on any load/s on any day.


Further interviews with the Vice President of Peri-Operative Services at approximately 11:30AM, revealed that the facility was transporting the soiled/contaminated surgical instruments to the Petrie Campus Central Sterile Department for Sterilization. Upon request for tracking documents for the surgical instruments sent out each day and for the sterilized packs received, the facility was unable to provide it and the Vice President of Peri Operative Services stated that the facility does not record or track any surgical instruments transported out or received after sterilization. It was also stated that the Central Sterile Department at Petrie Division was responsible for tracking the instruments.

Therefore, the facility (Brooklyn Campus) did not have the Biological Indicator(BI) test results and Chemical Indicator(CI) test results on-site for the sterilizers used to sterilize the surgical instruments.


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2. On July 01, 2015, at 11:23 am, during the tour of the OR at the Petrie site in accompaniment of an Executive Director/Infection Control MD, it was observed that a patient ' s Foley catheter and a part of the tubing fell down to the floor from the surgical table during repositioning of the patient. This observation was brought to the attention of the accompanying physician. The Foley catheter remained on the floor until the accompanying physician brought it to the attention of the OR staff. One of the OR staff members picked up the patient ' s Foley catheter from the floor and placed it on the surgical table by the patient in close proximity to the sterile field. The catheter was not positioned below the level of the patient ' s bladder.

The observation that the foley and its tubing was incorrectly positioned in close proximity to the sterile field after being picked up from the floor represents a potential for contamination and infection.