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Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of the Complaint Investigation for Complaint No. 172535 conducted on June 7, 2017, the facility failed to provide and maintain a safe environment for patients, staff and visitors.

Based on observations during the survey walk through, staff interview, and document review during the Life Safety Code portion of the Complaint Investigation for Complaint No. 172535 conducted on June 7, 2017, the facility failed to comply with the applicable provisions of the 2012 Edition of the NFPA 101 Life Safety Code.

See the Life Safety Code deficiencies identified with the K-Tags.

Based on document review and interview, it was determined that for 8 of 8 LuxTec Light Source boxes, the Hospital failed to ensure evaluation and inspection of equipment as required by policy.

Findings include:

1. The Hospital policy titled, "Medical Equipment Evaluation" (rev 2/15) reviewed on 6/8/17, required, "Purpose: To identify criteria use to determine medical devices to be included in the scheduled maintenance program. To establish inspection intervals of like support and non-life support for medical equipment included in the Biomedical Department scheduled maintenance program. Policy: The Biomedical Department shall provide a planned maintenance program designed to assess and control the clinical and physical risks of fixed and portable medical equipment used for the diagnosis treatment, monitoring, and care of patients. All devices will be assigned a Risk Score based on the following category: Equipment Function, Clinical Application and Maintenance Requirements as defined.

2. The Hospital policy titled, "Scheduled Service Maintenance" (rev. 6/16) reviewed on 6/8/17, required, "The policy describes the process of how each piece of equipment is tested, and documented at intervals determined by the manufacturer recommendations, risk levels and equipment history...The Healthcare Technology Management department (HTM) develops written inspection procedures and /or Electrical Safety procedures for every asses/type of fixed or portable medical equipment in the scheduled maintenance program."

3. The schedule of maintenance for the LuxTec Light Source was requested on 6/7/17. The schedule of maintenance for the LuxTec Light Source was not available. The maintenance reports for the LuxTec Light Source indicate that 4 were inspected on 3/2016 and 4 were inspected on 4/2016, when the equipment first arrived. One box was returned to the manufacturer for repair under the warranty on 4/20/17.

4. The Manufacturer's recommendation for maintenance and cleaning for the LuxTec Light Source required, "Use a vacuum cleaner and a soft brush to remove visible dust accumulation from the fan and vent holes whenever necessary and always when replacing the lamp."

5. The Assistant Director (E #4) of HTM (Health Technology Management) was interviewed on 6/7/17 at approximately 11:30 AM and 6/9/17 at approximately 9:15 AM. The schedule for maintenance and "Medical Equipment Evaluation" for the LuxTec Light Source boxes was requested. E #4 stated that the LuxTec boxes were initially inspected at the time of delivery (3/2016 and 4/2016) from manufacturer and was the last inspection. E #4 stated that the LuxTec Light Source boxes were not on a schedule for maintenance. E #4 stated that there was no "Medical Equipment Evaluation" (equipment risk evaluation) done on the LuxTec Light Source boxes.

Based on observation, document review and interview, it was determined that for 7 of 11 staff (E #11, 12, 13, 14, 15, 16, & 17) personnel observed, the Facility failed to ensure adherence to attire policy in the operating room (OR).

Findings include:

1. During observational tour of the surgical suites on 6/8/17, the following were observed:

-At approximately 10:05 AM an Anesthesia Resident (E#12) entered OR 15 with his beard uncovered.
-At approximately 10:15 AM, a Registered Nurse (E #11), was in OR 12 with strands of hair around her ears and at the back of her neck.
-At approximately 1:40 PM, during a tour of the surgical instrument reprocessing area, a hospital staff (E #16), was standing in the decontamination area wearing street clothes.
-At approximately 2:30 PM at OR 7, E #13, E #14 & E #15 entered the room with open surgical packs holding their masks over their mouths and noses with the ties hanging down, unfastened.
-The Scrub Technician ( E #17) in OR 7, was wearing a personal cap under a bouffant cap, with approximately 2 inches of the personal cap exposed.

2. The Facility policy titled, "Procedural/Surgical Attire: Staff" (rev12/16), reviewed on 6/8/17 required, "All persons who enter the semi-restricted areas of the surgical/procedural suite should wear attire intended for use with the procedural/surgical suite. All procedural/surgical personnel and visitors...must change their present clothing to scrub attire... Jumpsuits can only be worn by...hospital employees in case of emergent need.... Surgical Scrub Hats 3. Should be worn in such a manner that all hair is covered and secured under the hat. Types of hat: Hoods-are to be worn if the person has long sideburns and/or a beard; a reusable scrub had can be worn but only if it is covered by a disposable bouffant. Surgical Masks: surgical masks should be adjusted so that they cover the nose and mouth and fit snugly to the face without any venting of the mask.

3. The above findings were discussed with the Clinical Nurse Specialist (E #8) during the observational tours. E #8 stated that personnel should follow all of the surgical attire policy including all hair being covered, masks fastened when entering suites with open packs, and the wearing of scrub attire, or at the very least, a jumpsuit in the unit.