HospitalInspections.org

An un-announced Verification Visit was performed on July 9-11, 2013 from a Recertification Survey for Life Safety Code compliance. The full survey was conducted by the Wisconsin Division of Quality Assurance on 05/13/2013 - 05/16/2013. The Wheaton Franciscan Health - St. Joseph Hospital was found to be NOT in compliance with the following regulation:

42 CFR 482.41 Condition of Participation: Physical Environment was NOT MET
42 CFR 482.41(b) Standard: Safety from Fire was NOT MET

The cumulative effect of the following (A-TAG) deficiencies has the potential to affect the safety of all patients, staff, and visitors at the hospital:

FINDINGS INCLUDE:
K11: Unreliable building separation.
K15: Interior room finishes without flame spread ratings.
K17: Smoke tight corridors are not maintained.
K18: Ineffective latching and non-protected openings into the corridor.
K20: Compromised vertical shaft ratings.
K21: Rating doors on hold-open without automatic closing feature.
K22: Access to exits without readily visible signs.
K24: Smoke Compartments with inappropriate configurations.
K25: Smoke Compartment walls were not smoke tight.
K27: Smoke barrier doors were not smoke tight.
K29: Unreliable enclosure of hazardous areas.
K32: Exits were not provided or properly remote from each other.
K33: Exit enclosures are open to an unoccupied space.
K38: Access to exits was not accessible.
K39: Egress corridors were undersized.
K40: Egress doors were undersized.
K50: Fire drills were not conducted under varied conditions.
K51: Fire alarm system was not compliant to NFPA 72 minimum standards.
K52: Fire alarm system was not fully tested to NFPA 72 standards.
K56: Sprinkler system was not compliant to NFPA 13 minimum standards.
K67: The ventilation system did not meet NFPA 90A minimum standards.
K69: Kitchen was not properly protected per NFPA 96.
K74: Loosely hanging fabrics lacked treatment.
K78: Smoke removal not provided for an indoor anesthetizing location.
K130: Miscellaneous provisions not found in other K-tags.
K147: Electrical system is not to NFPA 70 minimum standards.

Please refer to the full description and findings within the specific K-tag deficiencies within the appropriate Building found later in this report. (A-0709)
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(A-0701)
The hospital failed to maintain walls free of damage, counters free of damage, cabinets free of damage, and ceilings free of damage.
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(A-0713)
The facility potentially placed all patients, visitors and staff at risk by not keeping the surrounding area of refuse bins free from debris.
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(A-0726)
The facility failed to provide proper ventilation that had potential of cross-contamination of air with undesirable contaminants, and causing possible infection for all patients receiving services at this hospital. This observed situation is not consistent with CDC guidelines, AIA guidelines, and manufacturer recommendations.
(A-0726)
The facility did not construct, install and maintain a proper ventilation and temperature control system in pharmaceutical, food preparation, and other appropriate areas.

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ITEM #1
Based on observation and interviews the hospital failed to maintain walls free of damage, counters free of damage, cabinets free of damage, and ceilings free of damage in 2 of 3 hospital locations (St Joseph's and Elmbrook Memorial).

FINDINGS INCLUDE: (These observations occurred at St Joseph's Hospital.)

1. On 05/15/13 at 2:40 pm, observation revealed on the second floor near bathroom #2303 in Smoke Compartment 2-K, that a portion of a wall was damaged and in need of repair. The wheelchair alcove wall, by bathroom #2303, had exposed dry wall due to wall damage. This damage renders this surface porous and non-cleanable.

2. On 05/16/13 at 8:44 am, observation revealed on the Second floor room #N2503 A-N, ICU waiting area, that a portion of a wall was damaged and in need of repair. The walls were noted to be damaged throughout the ICU waiting area. This damage renders this surface porous and non-cleanable.

3. On 05/16/13 at 9:53 am, observation revealed on the Third floor in the OR #2, that a portion of a wall was damaged and in need of repair. The South and North walls were dirty and damaged with drywall exposed in some areas. This damage renders this surface porous and non-cleanable.

4. On 05/16/13 at 9:35 am, observation revealed on the Third floor in the Room #3214, that a portion of the counter was damaged and in need of repair. The counter-top in the Soil Utility Room was damaged and porous. This damage renders this surface porous and non-cleanable.

5. On 05/16/13 at 10:41 am, observation revealed on the Third floor in the Room #335C, Smoke Compartment 3A, that a portion of the ceiling was damaged and in need of repair. The ceiling was damaged from water leakage.

6. On 5/13/2013 at 4:40 pm, observation revealed on the 2nd floor in the OR #15, that a portion of the cabinetry was damaged, showing bare wood, and in need of repair. This damage renders this surface porous and non-cleanable.

The above physical conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M10 (EUA) and staff M11 (Architectural Designer).
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ITEM #2
During a tour on 05/13/13 from 11:25 AM to 4:00PM with CDC PP, the following concurrent observations and interviews identified damage to the physical environments as follows:
*Clean storage room (#7029) had 7 ceiling tiles falling down.
*Ceiling tiles in clean storage Room #3218C were falling down.
*Soiled Utility Room #3214 had chipped counter tops and gouges in the walls making surfaces porous and non-cleanable.
*Clean storage Room #2319 had gouges in the walls.
The above findings were confirmed by CDC PP at the time of discovery.
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ITEM #3
On 5/13/2013 from 11:21 AM to 11:55 AM, a tour with Nurse Educator L and concurrent observations and interviews identified the following:
*Biohazard room #2223 had a floor with cracked stone tiles, the wall had gouges and the ceiling air vent had dirt/debris on the louvers.
*The hallway leading to the ICU had cracked floor tiles, gouges in the dry wall and areas where the vinyl wall trim was separating away from the floor exposing the sub floor.
*The ICU waiting area had gouges in the dry wall.
*Chairs in rooms #1, 2, 3, 5, 6, 7, 8, 10, and 11.had cracked vinyl coverings.
*The ICU charting station had broken laminate.
The above findings were confirmed with Nurse Educator L at the time of discovery.
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ITEM #4
*On 5/13/13 from 1:20 PM to 2:55PM, a tour with Nurse Educator L and concurrent observations and interviews identified the following:
*The hallway of the catheterization lab to Rooms #1 & #2 had cracked tile flooring.
*The recovery bay had gouges in the drywall.
*The pre-operative holding area for surgery had a back counter with broken laminate.
*The medication room had holes in the drywall and wall tiles.
*The GI area procedure room #1 had a large hole in the flooring, gouged drywall, a piece of laminate flooring was missing in the storage closet.
*The dictation area within the recovery area had gouges in the drywall.
*Recovery rooms #2, 3, 4, and 6 had gouges in the drywall..
*The day surgery charting station had gouges in the laminate.
*Patient Rooms #10, 11, 14, and 17 had vinyl molding coming off the wall exposing underlayment.
*The decontamination room had cabinets that had rust and had chipping, peeling paint throughout the area.
The above findings were confirmed with Nurse Educator L at the time of discovery.
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ITEM #5
On 5/14/2013 at 7:35 AM, during a tour with CDC BB, and concurrent observations and interviews identified the following:
*Surgery Rooms #4, 5, 6, 7, 8, 9, 10, 11, and 15 had broken wall tiles, broken laminate counters/cabinets and gouges in the drywall.
The above findings were confirmed with Clinical Development Coordinator BB at the time of discovery.
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ITEM #6
These observations occurred at Elmbrook Memorial Hospital:
*During an observation on 5/15/13 at 9:05 AM, on the 5th floor, the clean storage room had linoleum flooring (approximate 7 inch wide by 2 foot long) that was warped and missing exposing the floor concrete surfaces.

*The same clean storage room had a marred surface exposing porous plaster (approximate 3 foot long gash at the height of between 5-6 feet high) on the wall.

*The 6th floor pt care area on 5/15/13 at 8:15 AM, the storage alcove across from Rooms #644 / #641 had marred gouged walls exposing porous plaster that could not be cleaned.

During an interview with V.P. SSSS on 5/15/13/at 3:00 PM, stated that a Work Order to fix the flooring was submitted to the Maintenance Department on 10/17/12.
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ITEM #7
These observations occurred at Elmbrook Memorial Hospital:

A tour of the 4th floor was conducted on 5/13/2013 from 11:25 AM-11:55 AM and again from 1:30 PM-3:30 PM accompanied by RN Edu C. The 4th floor consisted of Cardiac, Pulmonary, and Post-Partum units, and a closed short stay Cardiac unit.
The following observations were made on these units:
*Laminate on doors and counters was chipped and/or missing in several work areas and patient rooms.
*In several patient rooms and utility rooms there were chips and gouges in the dry wall revealing the porous, non-cleanable surface underneath.
*A large strip of molding along the kick board in Room #4153 is missing.
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A Recertification Survey for Life Safety Code compliance was conducted by the Wisconsin Division of Quality Assurance on 05/13/2013 - 05/16/2013. The Wheaton Franciscan Health - St. Joseph Hospital was found to be NOT in compliance with the following regulation:

42 CFR 482.41(b) Standard: Safety from Fire was NOT MET

The cumulative effect of these K-tag deficiencies has the potential to affect the safety of all patients, staff, and visitors at the hospital.

FINDINGS INCLUDE:
K11: Unreliable building separation.
K15: Interior room finishes without flame spread ratings.
K17: Smoke tight corridors are not maintained.
K18: Ineffective latching and non-protected openings into the corridor.
K20: Compromised vertical shaft ratings.
K21: Rating doors on hold-open without automatic closing feature.
K22: Access to exits without readily visible signs.
K24: Smoke Compartments with inappropriate configurations.
K25: Smoke Compartment walls were not smoke tight.
K27: Smoke barrier doors were not smoke tight.
K29: Unreliable enclosure of hazardous areas.
K32: Exits were not provided or properly remote from each other.
K33: Exit enclosures are open to an unoccupied space.
K38: Access to exits was not accessible.
K39: Egress corridors were undersized.
K40: Egress doors were undersized.
K50: Fire drills were not conducted under varied conditions.
K51: Fire alarm system was not compliant to NFPA 72 minimum standards.
K52: Fire alarm system was not fully tested to NFPA 72 standards.
K56: Sprinkler system was not compliant to NFPA 13 minimum standards.
K67: The ventilation system did not meet NFPA 90A minimum standards.
K69: Kitchen was not properly protected per NFPA 96.
K74: Loosely hanging fabrics lacked treatment.
K78: Smoke removal not provided for an indoor anesthetizing location.
K130: Miscellaneous provisions not found in other K-tags.
K147: Electrical system not to NFPA 70 minimum standards.

Please refer to the full description and findings within the specific K-tag deficiencies within the appropriate Building found later in this report.

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Based on observation and staff interview, the facility did not construct, install and maintain a proper ventilation and temperature control system in pharmaceutical, food preparation, and other appropriate areas. The facility did not have and a ventilation system that was installed and maintained in accordance with CDC guideline, AIA guidelines and manufacturer recommendations. This deficient practice could affect all patients, staff, and visitors in 40 of the 92 smoke compartments.

The facility also did not provide proper ventilation due to a lack of positive pressure int hree spaces and a lack of negative pressure in one space. These deficient practices had a potential of cross contamination of air with undersirble contaminants and causing posile infectin for all patients receiving services at this hosptial.

The CDC guidelines can be found in the website


FINDINGS INCLUDE:

1. On 5/14/2013 at 2:00 PM, observation revealed on the 8th floor between the clean room of the infusion pharmacy and the ante room, that the ventilation to the space could not be confirmed to be compliant with accepted standards. The air flow was going from positive to negative and then negative to positive without any apparent reason. They was observed by a tissue under the door.

2. On 5/15/2013 at 10:00 am, observation revealed on the 2nd floor (on the 1st floor roof) by the air handler near the old main entrance, that the ventilation to the space could not be confirmed to be compliant with accepted standards. The air intake was only 8 feet from the air exhaust. The CDC and AIA Guidelines require a separation distance of 25 feet between air intakes and air exhausts. Moss was growing on the roof, 2 feet from an air intake.

3. On 5/16/2013 at 9:58 am, observation revealed on the Basement floor in the sterile processing, that the ventilation to the space could not be confirmed to be compliant with accepted standards. Air flow was from substerile (receive area (dirty)) into sterile processing (clean). This air flow is in the wrong direction. The air shall go from clean to dirty.

4. On 5/16/2013 at 10:05 am, observation revealed on the Basement floor in the sterile processing room, that the ventilation to the space could not be confirmed to be compliant with accepted standards. The air grills between the sterile processing room and behind the sterilizers were covered in dirt and dust.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with staff M3 (HVAC Tradesman), staff M7 (EUA), staff M9 (Mechanic), and staff M13 (Risk Analyst).
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5. On 5/14/2013 at 9:10 am, observation revealed that the Clean Equipment & Case Cart Storage room adjacent to the male staff locker Room 2B456 on the 2nd Floor was not under positive pressure relative to adjacent spaces. It was instead under negative pressure causing airflow in the wrong direction from corridor to the clean storage.

6. On 5/14/2013 at 2 pm, observation revealed that the pressure monitor mounted on wall of the Operation Room #3 (OR3) opposite nurse station on the 2nd Floor showed a pressure differential reading of +0.0013 in. of water column, and was not at least +0.01 in. of water column recommended in the CDC and AIA guidelines.

7. On 5/15/2013 at 10:10 am, observation revealed that the Medical Waste Room GA152 in the Lower Level was under positive pressure relative to adjacent spaces, and not under negative pressure when tested with a one-ply toilet paper at the door undercut. The test showed the airflow direction from the waste room GA152 to corridor. The airflow was in a wrong direction from dirty to clean spaces.

8. On 5/15/2013 at 10:20 am, observation revealed that one leaf of the double corridor doors to the Clean Supply Storage GA144 in the Lower Level was held open with an electromagnetic hold-open device, and did not maintain positive pressure in the room relative to adjacent spaces to cause airflow from clean to dirty spaces.

These conditions were confirmed at the time of discovery by a concurrent observation and interview with Staff M4 (Director of Facilities-Elmbrook), Staff M15 (EUA), Staff M16 (Safety Coordinator), and Staff M22 (Mechanic). The above deficiency was also confirmed with Staff M1 (V.P. Facilities) at an exit conference on 05/15/2013 at 4:15 pm.

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29963

Based on observations in P&P review, and interviews, the hospital's equipment and supply maintenance system for 2 of 3 hospital locations (St. Joseph's, The Wisconsin Heart Hospital and Elmbrook Memorial), failed to secure hazardous chemical, failed to have an effective system in place to check, rotate and remove outdated products, and failed to monitor equipment and supplies for safety, integrity and security. Failure to maintain the physical environment has the potential to affect all patients, visitors, and staff in this hospital system.
Facilities Findings Include:
The facility's policy titled, "Environmental Cleaning, Sanitation, and Decontamination," dated August 2012, was reviewed on 5/15/2013 at 1:20 PM. The policy's rationale is to achieve excellence and use best practices which requires them to, "Adhere to environmental cleaning, sanitation, and decontamination by following best practice of CDC guidelines."
The policy's Part A. Summary states in part, "The environment includes but is not limited to: floors, carpeted and uncarpeted, walls, ceilings, doors, office and pt care furniture, wall and ceiling mounted equipment, cabinets, shelves, counters and other work surfaces, air vents, ducts..."
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Findings at Elmbrook Memorial Hospital:
Refrigerator Temperatures not monitored:
*During tour of the Elmbrook Hospital location on 5/15/13 at 8:06 AM, during a tour and concurrent observation and interview with Clinical Nurse Educator FFFF Laboratory Staff GGGG, the following was observed:
* In the laboratory area the 4 refrigerators had incomplete temperature logs for the date of 04/28/13, the refrigerator labeled "Biohazard Survey", Chemistry", "Co-ag", and "Urinalysis".
*The refrigerator labeled, "Processing" had a log showing that temperatures were not recorded on 5/12/13 and 5/13/13. When the missing temperatures were pointed out to Staff GGGG, GGGG said, "They must have missed it those days. Monitoring is to be done by the morning shift daily.
*The refrigerator log for the refrigerator in the grossing station room shows that temperatures were not recorded on the following dates from March 1 through May 14, 2013:
March 7, 15, 28, and 29, 2013
April 1, 2, 3, 4, 5, 7, 10, 24, and 28, 2013.
May 8, 9, 10, 11, 12, 13, and 14, 2013.
When Surveyor mentioned that there were numerous temperatures missing, staff GGGG said, "yes" and then provided a copy of the log.
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Physical Plant Observations:
Observations on 5/15/13 at approximately 9:05 a.m., of the 5th floor clean storage room reflects linoleum flooring (approx. 7 inch wide by 2 feet long) is warped and missing,exposing the floor concrete surfaces, that cannot be efficiently disinfected. One wall has a marred surface exposing porous plaster (approx 3 feet long gash at the height of between 5-6 feet high.) The clean storage room should have washable and intact wall surfaces to prevent transmission of infection to clean supplies.
Interview with V.P. SSSS on 5/15/13 at 3:00 p.m. reflects that a work order to fix the flooring was submitted to maintenance on 10/17/12, and has not been responded to yet.
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During the tour of 6th floor patient care area on 5/15/13 at 8:15 a.m., the storage alcove across from Rooms #644 & #641 had marred gouged walls exposing porous plaster that could not be cleaned.
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At 9:35 AM on 5/5/15/13 while touring the Cardio-respiratory area of the Elmbrook Hospital, accompanied by Supervisor IIII, the following concurrent observation and interview identified the following:
In Room #C212, a labeled EMG (Echo-Myogram), had 1 bottle of alcohol 70% sitting on the desk that had expired in July of 2009. When asked Supervisor IIII what the expiration date on the bottle was, IIII replied, "July 2009".
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Findings at St Joseph's Hospital:
On 05/13/13 from 11:25 AM to 4:00 PM, during a tour and concurrent observations and interview with CDC PP the following areas were identified and confirmed not to have a cleaning schedule or assigned staff accountable for cleaning:
*3rd floor NICU large common wash sinks debris had visible build up on the wall, sinks and sanitizer/cleaner dispensers.
*3rd Prenatal Assessment Department and 7th floor kitchenette had ice machines that had white debris built up around the dispensing spout and catch tray. Dust and debris was found on top of and underneath both ice machines.
*3rd floor NICU unit Laundering Room was also used for storage blocking the hand washing sink.
*SPECIAL NOTE: Per Facilities VV Review on 3th and 7th floors, Clean Storage Areas: (Rooms #3839C, #3149 were not scheduled to be completed as yet), (Room #3219 was not repaired on 07/11/2013), (Room #3218A was not repaired on 07/11/2013), (Rooms #3218C, #3214, #3010, #3050, #3051, #3041, #7029 and #7028 were not scheduled to be repaired as yet). These rooms were not on a cleaning schedule per nurse consultant review of records in the original survey.
*3th and 7th floors Soiled and Dirty Utility Rooms (3820B, 3810, #3214, #3043, #3115 and #7009) were not on a cleaning schedule.
*Air ventilation grills (for fresh air flow into the unit) were dusty with gray/black material clinging vent grills on 2 of 7 floors (#3 and #7) for 7 of the 7 pt care areas (Hospice, Oncology, L&D, Antepartum, Pediatric Stepping Stones, Prenatal Assessment Maternal Fetal Medicine & NICU), including their Storage Rooms.
*7th floor surveyor noted a stained carpet on the floor of a Clean Supply Room. 7th floor RN Manager XX stated, XX was not aware that carpet was not allowed in a clean storage area.
*At the time of discovery, CDC PP acknowledged both clean and dirty storage areas on the 3rd and 7th floor identified above had evidenced of debris and dust build up on the flat surfaces, storage racks storage bins and air vents.
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On 05/13/13 from 11:25 AM to 4:00 PM, during a tour and concurrent observations and interview with CDC PP and unit staff, the following supply areas were identified, not to have clearly marked expiration dates and no system to ensure product quality, and out dated products were not being removed from Pt care areas in the following areas:
*3rd floor NICU had 2 shipping boxes labeled " Mission Supplies". In an interview at 12:25 PM on 05/13/13, CDC UU and NICU Supervisor TT said the mission items are no longer useable on the NICU unit. TT and UU said they were unaware that unusable items should be separated from their Pt useable products.
*On 05/13/13 from 1:55 PM to 2:30 PM on a tour of the Ante-partum Unit Medication Room #3230, CDCP PP identified outdated blood collection tubes.
*On 2 of 7 floors (#3 and #7) in 6 of 7 (Hospice, Oncology, L&D, Antepartum, Prenatal Assessment Maternal Fetal Medicine & NICU), units, sterile product packaged by a MFR did not have an expiration date on them.
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On 05/13/13 during an interview, CDC PP discussed validity of sterility with NICU Pt Care Supervisor TT at 12:25 PM, 3rd floor L&D Supervisor SS at 2:40 PM and 7th floor RN Manager XX at 3:30 PM. TT, SS and XX, acknowledged that PP, TT, SS and XX were not aware that products came from the MFR without an expiration date.
*NICU Pt Care Supervisor TT (12:25 PM), 3rd floor L&D Supervisor SS (2:40 PM) and 7th floor RN Manager XX (3:30 PM) said, the hospital does not have a P&P for rotation of sterile products that come to the hospital without a clearly marked expiration date.
*NICU Pt Care Supervisor TT (12:25 PM), 3rd floor L&D Supervisor SS (2:40 PM) and 7th floor RN Manager XX (3:30 PM), acknowledged, TT, SS and XX were not aware of any monitoring done within the respective departments to ensure sterile packages were maintained at a temperature and humidity to ensure sterility for the sterile products shelf life.
*NICU Pt Care Supervisor TT (12:25 PM), 3rd floor L&D Supervisor SS (2:40 PM) and 7th floor RN Manager XX (3:30 PM), acknowledged, that TT, SS and XX did not know the shelf life for the sterile products identified as not having an expiration date within the respective departments.
*3rd floor NICU on emergency NICU response cart MFRs sterile packages were rubber banded, that include venipuncture needles and intubation tubes. Staff stated they were not aware that rubber banding sterile packages jeopardized the package integrity. At 12:25 PM, NICU Pt Care Supervisor TT said she was unaware that rubber banding sterile packages compromised their integrity and sterility.
*3rd floor NICU surveyor found 4 packages of outdated infant formula. S NICU Pt Care Supervisor TT (12:25PM), said TT acknowledged the outdated infant formula but TT said TT was unsure who was monitoring formula outdates, unit staff nurses or nutritional services.
*Medication Room #3230, Surveyor and CDC PP identified outdated blood collection tubes.
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On 05/13/13 from 11:00 to 4:00 PM, tours of the 3rd and 7th floors with CDC PP and concurrent observations and unit staff interviews identified the following equipment maintenance issues:
*7th floor Medication Room #7028 had a missing grill at the bottom of the medication refrigerator dust and debris were visible including a syringe cape and a roll of tape. On 05/13/13 at 3:30 PM, RN XX was not sure who was responsible for the maintenance of the refrigerator. However, XX did acknowledged the grill had been missing for a while.
*7th floor Room #7029 had a blanket warmer currently being used, but was missing its top and side panels. The insulation was duct taped in place. On 05/13/13 at 3:30 PM the 7th floor RN Manager XX, said, that XX was not aware of why the blanket warmer had no sides or top, or who maintained the blanket warmer or who would have ducted tape the insulation in place.
*3rd and 7th floors, had Computers-on-Wheels with dust and debris between the keys and in the housing frame. 3rd floor NICU Pt Care Supervisor TT at 12:25 PM, 3rd floor L&D Supervisor SS at 1:25 PM and RN Manager XX on the 7th floor at 3:30 PM, explained that staff are to wipe them down between pts, however there was no regular cleaning or maintenance scheduled for the computer key boards.
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A tour of the 4th floor was conducted on 5/13/2013 from 11:25 AM-11:55 AM and again from 1:30 PM-3:30 PM, accompanied by RN Edu C. The 4th floor consisted of Cardiac, Pulmonary, and Post-Partum units, and a closed short stay Cardiac unit. The following observations were made on these units:
*Room #4159, designated as a family waiting area, was being used for storage of wheel chair with an oxygen tank attached to them, a vital sign monitor, and other unsecured pt equipment.
*Soiled Utility rooms containing bio-hazard waste and sani-wipes (chemical cleaning wipes that indicate to keep out of reach of children on the label) were unlocked, allowing potential unauthorized access to chemicals and hazardous waste.
*On the post-partum unit, the soiled utility room had dirty surgical instruments in it and the door was unlocked.
*In the hallway outside of Room #4202 in the basket attached to the EKG monitor stand was a container of sani-wipes. There was a visiting child playing in the hallway in this area, who had potential to access the chemical wipes.
These findings were discussed with and confirmed by RN Edu C at the time of discovery on 5/13/2013.
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Findings at Elmbrook Memorial Hospital:
During a tour of the rehabilitation unit at Elmbrook on 05/15/13 at 9:20 AM with RN educ. CCCC dirty and scuffed walls were observed as well as dust clogged vents on the radiator/heating unit in both Room #466 and Room #473. These findings were confirmed by CCCC at the time of the tour.
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Findings at St Joseph's Hospital:
ITEM #243 IN THE POC:
A un-announced verification visit occurred on July 11, 2013 between 8:30 AM - 10:30 AM at WFH-St. Joseph Hospital, Basement, and found this deficiency not corrected. Per original survey review on 5/15/13 at 1:50 pm of facility policy titled "Hazardous Materials and Waste Management Plan", dated 1/2012, indicated under Rationale: The Hazardous Materials and Waste Management Program was developed to coordinate an effective hazardous materials safety program based on organizational experience, applicable laws, and regulations, and accepted practice. This includes maintaining a safe physical environment, inventory and safe handling of hazardous materials, monitoring associate e work areas, reviewing departmental policies and procedures, an implementing a hazardous material waste reduction program.
Per review on 5/15/13 at 1:50 pm of facility policy titled Hazardous Materials and Waste Management Plan, dated 1/2012 indicated under II. A. 2. Those chemicals defined as OSHA/EPA as hazardous are stored in areas accessed only by authorized personnel.
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A tour of the 5th floor was conducted on 5/13/2013 from 2:25 PM.-3:40 PM accompanied by RN Edu O. The 5th floor consisted of Medical, Surgical, and Post-Partum units. The following observations were made on these units:
*Soiled Utility rooms housing bio-hazard waste and sani-wipes (chemical cleaning wipes that indicate to keep out of reach of children on the label along with bottles of chemical cleaning supplies) were left unlocked.
*In several patient rooms there were upholstered chairs with cracks or rips in the material revealing a non-cleanable surface underneath.
*In several patient rooms built-in metal closets are utilized for medical supplies and pt belongings on the medical unit. The paint was chipped off and areas are noted to have rust.
*On 5 West in the patient food storage area were white plastic bins used to hold packets of salt, pepper, and sugar; the containers have crumbs, and debris noted at the bottom of the containers. These findings were confirmed at the time of the tour by RN Edu O.
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Per tour on 5/13/13 beginning at 11:45 am of the Materials Management area in the Basement level revealed the following:
*The room was filled with dirty/full bio-hazardous containers along with clean/unused bio-hazardous container with no distinct separation of clean/unused and dirty/full containers.
*Dirty/full bio-hazardous containers housed on the same wheeled metal cart with Empty/unused bio-hazardous containers.
Per interview with Director of Environmental Services (DEVS) P on 5/13/13 at 11:50 am, DEVS P stated the wheeled metal cart is used to exchange the bio-hazardous containers on the units. The cart is filled with unused containers and when a dirty/full bio-hazardous container is removed from the unit, it is placed on the cart and an empty/clean container is removed from the cart. Clean containers are stored next to contaminated containers increasing the risk of cross contamination.
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Per tour on 5/13/13 beginning at 12:00 pm of the Clean Laundry Storage Area revealed a large stainless venting mounted on the ceiling directly above the clean laundry carts, with an opening of approximately 3 ft by 2 ft which had a large accumulation of a thick layer of dust. Directly under the air vents were 8 laundry carts filled with clean linen which was uncovered. At time of tour laundry staff was at lunch.
Findings confirmed with Lead worker of Linen Room LWLR (Q) and RNN Edu O.
Per interview on 5/14/13 at 8:40 am with Director of Supply (DS) TTT indicated, that it is expected that staff would keep linen covered when not working immediately in that area to prevent possible contamination.
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Per tour on 5/14/13 at 11:25 am through 11:45 am of the Inpatient Dialysis Area revealed:
*Water room with dirt and debris noted on the floor.
*A buildup of white thick substance on top of the pipes leading from the bicarbonate and acid storage containers. Findings confirmed with RN Edu O at time of tour.
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Per tour on 5/13/13 beginning at 1:45 PM of the Material Management Room revealed room filled with metal shelving.
*Approximately 38 metal carts had a plastic covering on the bottom level of each shelf. A thick layer of dust noted on all the plastic coverings.
*Boxes of supplies were tipped over and individual packaged supplies were lying in the dust.
*Supplies noted out of original packaging included lab supplies, anesthesia packs, colostomy supplies, tape, intravenous supplies and ventilator supplies. Also noted 3 urinals laying on the floor in between the wood pallets. Findings confirmed with RN Edu O at time of tour.
Per interview with Distribution Attendant (DA) UUU stated that the Housekeeping Staff is responsible to clean the floor and material management staff is responsible to keep the shelving for the supplies clean. DA UUU stated there is no schedule to complete cleaning.
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On 5/13/2013, beginning at 11:21 AM a tour with Nurse Educator L was conducted. Bio-hazard Room #2223 was observed to be unlocked. The room contained a large biohazard bin with material inside and dirt accumulated in the corners. The air vent had dirt/debris on the louvers.
*The room contained a hopper sink. The sink had a dark brown film on the inside with chunks of brown debris clogging the drain. Nurse Educator L explained the room is used by the dialysis unit and the outpatient unit.
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On 5-13-2013 at 1:20 PM a tour with Nurse Educator L was conducted of the catheterization lab. It was observed the medication room had wash cloths stored under the sink.
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At 1:55 PM, the Post Anesthesia Care Unit (PACU) was observed. Bathroom was observed to have dirty ceiling air vent and floor tiles with accumulated dirt.
Across from pt Recovery Pod #11 was a large original shipping box. Nurse Educator L explained that original shipping boxes do come to pt care areas to be emptied.
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At 2:15 PM the GI area was observed. 34 GI scopes were observed hanging in the hallway outside of Procedure Room #2 un protected and uncovered exposing them to dust, debris and damage.
*Clean Storage Room #2106 was observed to have storage of diapers, syringes and suction canisters under the hand-washing sink.
*Original shipping box of Bair Paw gowns was observed in the clean storage room.
*Dirty Utility Room #2104 was observed to be unlocked and contained a biohazard container.
*Under the sink were pt positioning items.
*Pt Rooms #10, 11, 14, and 17 were observed to have dirty floors.
*Pt Room # 16 was observed to have no pt in the room and used IV tubing was still attached to a IV bag with the IV catheter inside a glove laying on the floor.
*The Laundry Chute Door to the was unlocked.
*At 2:55 PM the Decontamination Room was observed. The hopper sink behind the disassembly table was observed to have large amounts of white residue around and on the sink.
The above findings were confirmed with Nurse educator L at the time of discovery.
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On 5/14/2013 at 7:35 AM observation of Surgery Rooms #1, 2 and 3 with CDC BB, are used for currently used to perform surgical procedures are also being used to house unprotected storage.
The above findings were confirmed with CDC BB at the time of discovery.