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Based on record review and staff interview the governing body failed to review the hospital's contracted services that provide patient care to ensure that the contracted services providing patient care used by the hospital were provided in a safe and effective manner.

Findings include:

During facility record review there was no documentation provided to the surveyors that the governing body had a procedure in place to evaluate the quality of each contracted service that provides patient care to ensure the services were provided in a safe and effective manner.

In an interview with the facility Chief Executive Officer it was confirmed that the facility did not have a procedure in place to evaluate the quality of the services provided by their contracted services.

Based on record review and observation the facility failed to ensure that the medical equipment in their Cardiac Rehabilitation and Operating Room areas were tested to ensure the medical equipment was working properly and available for patient use.

Findings include:

During a tour of the facility surveyors observed that the Defibrillators located in the Cardiac Rehabilitation and the Operating Room areas were not being tested by facility staff to ensure the Defibrillators were working properly and ready for use on hospital patients.

The Facility Chief Executive Officer confirmed that there was no documentation available that shows the Defibrillators located in the Cardiac Rehabilitation and Operating room areas were being tested to ensure the equipment was working properly.

Based on review of facility documents, observation and staff interview, the facility failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There was no active program for the prevention, control, and investigation of infections and communicable diseases.

The facility failed to designate an infection control officer that developed and implemented policies governing control of infections and communicable diseases as the facility did not:
A. Maintain and complete a training and continuing education for staff responsible for sterilization.
B. Provide equipment adequate for sterilization of supplies and equipment.
C. Ensure policies for sterilization were adopted, implemented and enforced.
D. Review the sterilization policies at least every year.
E. Maintain performance records and preventive maintenance records for sterilizers.
Cross refer 482.42(a), Infection Control Officer.

The facility failed to identify, develop and implement an effective infection control program to prevent communicable diseases as the facility did not:
A. Maintain the facility in a sanitary manner.
B. Monitor Surgical Site Infections [SSI].
C. Use Immediate Use Steam Sterilization appropriately.
Cross refer 482.42(a)(1), Infection Control Program.

Based on review of facility documents, observation and staff interview, the facility failed to designate an infection control officer that developed and implemented policies governing control of infections and communicable diseases as the facility did not:
A. Maintain and complete a training and continuing education for staff responsible for sterilization.
B. Provide equipment adequate for sterilization of supplies and equipment.
C. Ensure policies for sterilization were adopted, implemented and enforced.
D. Review the sterilization policies at least every year.
E. Maintain performance records and preventive maintenance records for sterilizers.

Findings included:

A. Review of the personnel record for staff #9, the staff responsible for sterilization, revealed no documented proof of education, training or experience.
In an interview with staff #9, when asked about education, training, and experience, staff #9 stated, "I learned from the person who was here before me." When asked if they had received infection control training, staff #9 stated, "Yes," but when asked to provide documentation, none was provided.
Review of the personnel files for staff responsible for sterilization and using chemical disinfectants (staff #9, 10, and 16) revealed no evidence of continuing education, orientation or on-the-job training.
In an interview with the infection control coordinator, they verified the above. When asked if any orientation was completed, staff #9 stated, "We go through the process [with new employees]." When asked if there was any documentation on what was discussed, staff #9 denied any documentation.

B. AORN [Association of perioperative Registered Nurses] endoscope guidelines stated in part, "Processing Rooms or Areas: *Perform endoscope processing in a room where only processing activities are performed and that is physically separated from locations where patient care activities take place.
...*Maintain a unidirectional workflow from the decontamination area or room to the clean area or workroom and then to the clean storage location.
*Keep processing room doors closed.
...Processing flexible endoscopes in an area where temperature, humidity, environmental cleaning, surgical attire, traffic patterns, and security are management may improve efficiency, help maintain functionality of flexible endoscopes, reduce the risk of cross contamination, and provide a safe work environment.
...Storing
*Place flexible endoscopes in a drying cabinet
*If a drying cabinet is not available, store endoscopes in a closed cabinet with HEPA-filtered air that provides positive air pressure and allows air circulation around the flexible endoscopes.
...*Store mechanically processed flexible endoscopes in a cabinet that is either designed and intended for horizontal storage of flexible endoscopes or is of sufficient height, width, and depth to allow the endoscopes to hand vertically, without coiling and without touching the bottom of the cabinet.
...*Provide a distinct visual cue to clearly identify flexible endoscopes that are processed and ready for use.
...Effective storage of flexible endoscopes protects the endoscope and endoscope accessories from damage and reduces contamination to help ensure devices are safe for patient use."

Tour of the operating room area on 5/8/19 revealed endoscopes being processed in the "utility room/scope room" that had several holes in the walls; one hole behind the sink exposed a discolored metal sheet to the processing area. There was old equipment stored in the room. After scopes are processed and cleaned, staff hang them in this area, on a hook and lay the scope across the counter to the sink to drain and dry.

The storage cabinet for the endoscopes was not ventilated and the height was not sufficient to vertically hang each scope; the scope ends were touching the bottom of the cabinet.

When asked how many scope procedures were performed in the facility, staff #16 stated, "About three a month."

The above was confirmed in an interview with the CEO on the afternoon of 5/8/19.

C. Facility-based policy titled "Spore testing for Autoclaves" stated these should be performed every week.

In an interview with staff #9 on the afternoon of 5/7/19, when asked if these are completed, staff #9 stated, "We don't have to do those for our autoclaves."

Facility-based policy titled "Endoscopic Procedures" did not outline how to process, disinfect, transport or store scopes.

There were no policies addressing immediate use steam sterilization and surgical site infection surveillance.

The above was confirmed in an interview with staff #9.

D. Review of the facility-based policy titled "Distribution of Standardized Policy & Procedures" stated in part, "Policy Statement - Standardized Policies & Procedures will effect coordination of the principles of Infection control throughout the hospital and will assist the Infection Control Committee in their annual review of all departmental Policies & Procedures pertinent to Infection Control.

Review of infection control policies revealed a statement of authority that stated the Infection Control Committee has authority in infection control policies and procedures, which was signed 12/15/10. Many of the infection control policies were undated. The "Infection Control Committee," "Distribution of Standardized Policy & Procedures," and "Infection Control Methods of Surveillance" were last revised/reviewed in August of 2007.

The above was confirmed in an interview with the CEO on 5/8/19.

E. Sterilization logs for 2019 revealed not all loads documented, no indication of the contents of each load, identification of operator(s), results of biological tests and dates performed.

In an interview with staff #9, when asked about loads #1-6 on 4/11/19, which were blank, staff #9 stated, "I know what those were. Those are eye instruments." When asked why nothing was documented, staff #9 stated, "It's just us. We know what we sterilized." When asked about endoscope processing logs, staff #9 stated, "We don't have one." When asked how they know which scope was used on which patients, staff #9 stated, "We only use one colonoscope ... We only have one upper ..." When asked how they could be sure a clean scope was used if there was no documentation, staff #9 verified they could not.

Amsco manual for the autoclave sterilizers stated in part, "Routine Maintenance ... Daily ... 1. Clean chamber as follows:
a. Wash inside of chamber ...
b. Rinse ...
c. Remove chamber drain strainer ...
Weekly ...
a. Remove chamber drain strainer ...
b. Rinse ..."

When asked staff #9 about preventive maintenance, staff #9 stated, "I don't do it, that's all [staff #16]."

In an interview with staff #16, when asked about preventive maintenance, staff #16 stated, "Once a month, we use a de-scaler ..." When asked about removal of the drain daily, staff #16 stated, "I don't do it daily, but whenever I take it out, there's never anything in there."

There was no policy and no log regarding preventive maintenance. The above was confirmed in an interview with staff #9.

Based on review of facility documents and staff interview, the facility failed to identify, develop and implement an effective infection control program to prevent communicable diseases as the facility did not:
A. Maintain the facility in a sanitary manner.
B. Monitor Surgical Site Infections [SSI].
C. Use Immediate Use Steam Sterilization appropriately.

Findings included:

A. "OSHA/Blood Borne Pathogen Regulations Policy #138-030-060" stated in part "The facility provides sufficient housekeeping and maintenance personnel to maintain the interior and exterior of the facility in a safe, clean, orderly, and attractive manner."

Facility-based policy titled "Housekeeping" stated in part, "1. Routine Cleaning of Patient Rooms:
a. All soil and dust shall be removed from surfaces with a clean cloth and a hospital grade disinfectant registered by the EPA.
b. This includes horizontal surfaces, especially bed frames, examining lights ... furniture, and windowsills ...
6. Care and Cleaning of Equipment:
...c. Keep storage area for supplies clean and orderly."

Tour of the facility on 5/7/19 with the CEO revealed the following:
*Education Hallway had three over-head lights with dead bugs visible
*Patient room #9:
-Layer of dust on the two over-bed lights
-Several small holes in the walls throughout, allowing an area insects and other pathogens can enter the facility
*Three water stained ceiling tiles in the hallway by Respiratory Therapy
*Five water stained ceiling tiles in the laundry room.
*Washing machine has a yellow residue on the washer barrel and rust like corrosion surrounding the bleach reservoir.
*Sonogram bathroom has crutches and glass panels stored in the shower stall.
*Housekeeping closet has two missing ceiling tiles.
*OB room has large pieces of torn wall paper.
*Labor room #1:
-Chips in paint throughout the room, making it impossible to clean
-Several cracked and discolored ceiling tiles throughout
*Several chips in paint and on doors throughout the facility
*Several cracked and discolored ceiling tiles throughout the facility
The above was verified on the tour with the CEO.

B. No facility-based policy regarding Surgical Site Infection surveillance was found. Facility-based policy titled "Infection control Methods of Surveillance" did not address SSIs.
In the infection control binder, "CDC Definitions of Nosocominal Infections" was reviewed and stated in part, "Definition: An organ/space SSI involves any part of the body, excluding the skin incision, fascia, or muscle layers, that is opened or manipulated during the operative procedures ... An organ/space SSI must meet the following criterion:
Infection occurs within 30 days after the operative procedure if no implant is left in place or within one year if implant is in place and the infection appears to be related to the operative procedure ..."

In an interview with the infection control director on 5/8/19, when asked the time-frame on SSI, they did not know. When asked if SSIs are monitored, they stated, "If they come to the clinic, we'll follow them." When asked if there was any documentation, they stated, "No." When asked if they do follow-up calls, they stated, "We'll sometimes do a post-op, but that would be within a couple of days."

C. AORN [Association of perioperative Registered Nurses] journal article stated in part, "Flash sterilization was designed for use in the OR for emergent and immediate use of a forgotten or unanticipated instrument or one that was accidentally dropped on the floor ... That flash sterilization may be overused to compensate for insufficient inventory of instruments, to save time, and for reasons of convenience is an issue of concern." Carlo, A. (2007). The New Era of Flash Sterilization. AORN journal, 88(S2), S68-80.

In an interview with staff #9, when asked about loads #1-6 on 4/11/19, which were blank, staff #9 stated, "I know what those were. Those are eye instruments ... These are flashed ... We have to flash eye instruments because they don't bring enough."

The above was confirmed in an interview with the CEO on the afternoon of 5/8/19.

Based on record review and staff interview the facility failed to provide an activities program that is based on the comprehensive assessment and care plan and the preferences of each resident and the facility also failed to ensure the activities program was directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who is licensed or registered, if applicable, by the State in which practicing.

Findings include:

In an interview with the facility Chief Executive Officer it was confirmed that the facility did not have an activities program directed by a qualified activities professional at the time of the survey.