HospitalInspections.org

Based on document review and interview, it was determined the facility failed to use the data collected to identify opportunities for improvement and implement effective measures to improve patient safety and quality of care.

Findings include:

Review of facility "Monitoring Tool" of data collected from August 2017 to July 2018, revealed, each month there were errors with sterilization of trays used for surgical procedures. These errors included the presence of bone, bioburden (blood or bone), hair, tissue, unidentifiable black debris, foreign material, disposable blood vessel clamps and bone cement in the trays that had been sterilized.

The "Action" documented on the Monitoring Tool From August 2017 to July 2018, states:
Staff would be re-educated, warned or disciplined for these errors and findings. Staff F, Central Sterile Technician would be re-educated in December 2017 and Staff F would be re-educated/warned twice in January 2018. Staff G and H, Central Sterile Technicians, would be disciplined in January 2018.

There was no documented evidence that these actions were taken. There was no documentation of monitoring of the sterilization process and the sterilization technicians.

There was no documentation of the investigations of these incidents to identify opportunities for improvement.
There was no documentation that corrective measures were implemented to prevent these incidents from recurring.


The facility's "Quality, Performance Improvement, Patient Safety and Patient Experience Plan" for 2018 states the responsibility of the Quality Improvement Committee is to "maintain and improve clinical and operational quality throughout the organization." The plan also states "undesirable patterns or trends in performance will be closely analyzed."

This plan was not implemented for these undesirable patterns.

These findings were shared with Staff A, the Corporate Director of Accreditation and Regulatory Compliance on 9/4/18 at 4:00 PM.