HospitalInspections.org

.
Item #1 Nutrition room cold holding

Based on document review, observations, and interviews, the hospital failed to develop, implement, and maintain active surveillance to prevent exposure to infectious diseases, including food borne diseases.

Failure to implement an active and appropriate hospital surveillance program for infection preventions and control with policies and procedures consistent with national guidelines places patients and staff at risk of illness from exposure to communicable disease.

Reference: FDA Food Code 3-501.16

Findings included:

1. Document review of the hospital's policy titled, "Food Service Food Safety," PolicyStat ID 10850329, approved 09/21, showed that all food will be stored, held, or cooked to the appropriate temperature; foods will be stored or held below 41 degrees F or above 135 degrees F.

2. On 06/27/23 at 3:10 PM, during an inspection of the Nutrition Room on the 10th floor patient care area, Investigator #6 used a thin-stemmed thermometer to assess the temperature of TCS (Time/Temperature Control for Safety) foods: non-fat milk, and a deli-sliced turkey sandwich. The assessment showed that the non-fat milk was held at 46.8 degrees Fahrenheit, and the turkey sandwich was held at 46.3 degrees Fahrenheit.

3. At the time of the observation, the Environmental & Linen Services Director (Staff #610) confirmed the temperatures. The non-fat milk and 1 of 1 turkey sandwich were discarded.

4. On 06/27/23 at 3:35 PM, during an inspection of the Nutrition Room on the 8th floor patient care area, Investigator #6 used a thin-stemmed thermometer to assess the temperature of non-fat milk, and a deli-sliced turkey sandwich. The assessment showed that the non-fat milk was held at 43.2 degrees Fahrenheit, and the turkey sandwich was held at 44.3 degrees Fahrenheit.

5. At the time of the observation, Staff #610 confirmed the temperatures and contacted the Food Services Manager (Staff #611). The non-fat milk and 3 of 3 turkey sandwiches were discarded.
.
Item #2 Patient care supplies

Based on observation and interview, the hospital failed to protect clean supplies and equipment from sources of contamination.

Failure to prevent contamination of patient care supplies places patients at increased risk of exposure to harmful microorganisms.

Findings included:

1. On 06/27/23 at 3:35 PM, Investigator #6 and the Environmental & Linen Services Director (Staff #610) toured the Nutrition Room on the 8th floor patient care area. The observation showed a tray with four 1000 mL bags of SpikeRight Plus (tube feeding nutrition) adjacent to the handwashing sink and directly below the paper towel dispenser.

2. At the time of the observation, Staff #610 confirmed the finding, moved the tray from the splash zone around the sink and stated that staff would be directed to keep patient care supplies away from sinks and other sources of contamination.
.
Item #3 Damaged mattress pads

Based on document review, observation, and interview, the hospital failed to ensure that staff removed damaged procedure bed mattresses in operating rooms.

Failure to remove torn or damaged mattresses hinders effective cleaning and disinfection of patient care equipment used in operating rooms and puts patients and staff at increased risk of exposure to infection.

Reference: Association of peri-Operative Registered Nurses (AORN) Guidelines for Perioperative Practice: Environmental Cleaning (2020) Recommendations 2.13.1 Remove and replace damaged or worn mattress coverings.

Guidelines for Environmental Infection Control in Health-Care Facilities. Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC). 2003, Updated 07/19. Part II Recommendations for Environmental Infection Control in Health-Care Facilities: G. VII. c. Maintain the integrity of mattress covers, replace mattress covers if they become torn or otherwise in need of repair.

Findings included:

1. Document review of the hospital's policy titled, "Environmental Services Procedure for Cleaning Surgical Areas (Terminal and Between Case)," PolicyStat ID 10904193, approved 04/21, showed that staff are directed to report any potential maintenance concerns for surfaces/items in need of repair to their supervisor. AORN is cited as a reference in this policy.

Document review of the STERIS® Instructions for Use (IFU), "Cleaning Instructions for STERIS Mattresses and Pads," document number P150830-913, 04/12/19, showed that users should inspect mattresses prior to and/or after use to check for mattress integrity. The use of H2O2 (hydrogen peroxide) and PAA (peracetic acid) is strongly discouraged for use on all STERIS products.

Document review of the STERIS® document titled, "Maximize the Life Expectancy of Your Surgical Table Mattresses and Pads," document #M10380EN.2020-03, showed that users are advised not to use cleaning agents designed for use on hard, non-porous surfaces, and to ensure adequate rinsing of cleaning agents and disinfectants from fabric.

Document review of the manufacturer's IFU for OxyCide (a H2O2-Peroxyacetic Acid) one-step disinfectant cleaner showed that OxyCide is designed for general cleaning and disinfecting hard, nonporous inanimate surfaces.

2. On 06/27/23 between 10:30 AM and 10:40 AM, Investigator #4 and Investigator #6 observed the between case cleaning of OR #1 by 2 Perioperative Services Technicians (PST), (Staff #603 & Staff #604), and an Anesthesia Technician (Staff #605). The observation showed a tear (approximately 5-inches long) in a seam of the center mattress pad on the procedure bed.

3. At 10:40 AM, Investigator #4 and Investigator #6 interviewed Staff #603 and an Infection Preventionist (Staff #601) about the between case cleaning. Staff #603 stated that the torn mattress pad cover was on a new mattresses pad. She stated that the disinfectant in use is OxyCide. An Infection Preventionist (Staff #601) stated, "OxyCide is eating the thread on the mattress pads."

4. On 06/27/23 between 6:20 PM and 8:10 PM, Investigator #6 observed the terminal cleaning of Operating Room #5 by a Housekeeper II (Staff #606). The observation showed that 2 of 3 procedure bed mattress pads were torn or damaged: the center mattress pad had a tear (approximately 3-inches long) in a seam; another mattress pad had a nickel sized hole in its side that exposed the foam padding.

5. At 7:40 PM, Investigator #6 interviewed Staff #606 and the Operating Room Manager (Staff #607) about the terminal cleaning. Staff #606 stated that she did not notice any equipment that needed to be repaired or replaced. Staff #607 stated that mattress pads should be replaced as soon as damage is observed. Both damaged mattress pads were removed.
.
Item #4 Operating room terminal cleaning

Based on observation, interview, and document review, the hospital failed to implement effective infection control and sanitation practices during terminal cleaning of the Operating Room (OR).

Failure to effectively clean the OR places patients and staff at risk of exposure to harmful microorganisms.

Reference: Association of periOperative Registered Nurses (AORN) Guideline for Environmental Cleaning (2020) - Recommendation 4.4.1 Clean and disinfect the exposed surfaces of all items.

Findings included:

1. Document review of the hospital's policy titled, "Environmental Services Procedure for Cleaning Surgical Areas (Terminal and Between Case)," PolicyStat ID 10904193, approved 04/21, showed that staff are directed to wash surfaces, including rubber hoses, using disinfectant solution. AORN is cited as a reference in this policy.

2. On 06/27/23 between 6:20 PM and 8:10 PM, Investigator #6 observed the terminal cleaning of Operating Room #5 by a Housekeeper II (Staff #606). The observation showed:

a. Ceiling outlet medical gas lines were not dusted or disinfected. A layer of dust was visible on the gas lines.

b. The gas lines near the anesthesia cart were bundled together with a cloth and tape (absorbent, non-cleanable surfaces).

3. At 7:40 PM, Investigator #6 interviewed Staff #606 and the Operating Room Manager (Staff #607) about the terminal cleaning. Staff #606 stated that she did not notice the layer of dust on the gas lines and did not know when they were last dusted or disinfected. Staff #607 confirmed the findings and removed the cloth and tape.
.
Item #5 Surgical attire

Based on document review, observation, and interview, the hospital failed to implement its policy for surgical attire in the restricted areas of the surgical environment.

Failure to ensure that staff members follow hospital policy for surgical attire places patients at risk for developing infections.

Reference: Association of periOperative Registered Nurses (AORN) Guideline for Surgical Attire (2023) - Recommendation 5.2 Cover a beard when entering the restricted areas.

Findings included:

1. Document review of the hospital's policy titled, "Surgical Attire," PolicyStat ID 13170048, approved 02/23, showed that head coverings must be worn in the semi-restricted and restricted areas, facial hair not confined by a mask must be covered, and masks should cover both mouth and nose and be secured in a manner that prevents venting. AORN is cited as a reference in this policy.

2. On 06/27/23 at 10:30 AM, Investigator #4 and Investigator #6 observed 2 staff members (Staff #608 and Staff #609) transporting a patient from Operating Room 1. The observation showed that Staff #608 was not wearing a beard cover or mask, and Staff #609's mask was not secured over his mouth and nose.

3. At the time of the observation, the Operating Room Manager (Staff #607) confirmed the observation and stated that the hospital's policy is for beards to be covered and masks to be secured over the mouth and nose.
.