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Based on interview and record review the facility failed to take actions aimed at performance improvement by failing to not consider the incidence, prevalalence and severity of patient safety and quality of care in 1of1 Patient ID #1.

Findings include:

Infection that was aquired by Patient ID #1 was reported within 24 hours from his outpatient procedure to the attending physician; who then reported to the facility. The facility failed to take actions aimed at performance improvement by not following their policy and procedure of presenting to Quality Improvement, and Medical Executive Committee for opportunities for improvements.

Interview with (CNO) Chief Nursing Officer, ID # 53 reported she had been the Quailty Improvement Director prior to being the CNO, and is familiar with the facility process for reporting inhouse and out patient infections. She reported the process for reporting any infections that occur within the hospital, and or outpatient areas are to be collected and brought to Quality Improvement who then presents to Medical Executive Committee for discussion at CQI meeting. Nurse #53, when asked by surveyor to show the minutes containing the report submitted to infection control for tracking purposes, could not find or produce the data. She stated," it should have been reported to MED Executive, but I do not see it in any of the reports that it was presented for discussion".


Record Review on 3/7/18 at 1:00 pm of Houston Physicians Hospital CQI Committee Meeting Minutes did not show evidence that the infection developed by Patient ID #1 reported to Infection Control by physician ID #56 had been presented to the Committee.
No evidence from MED Executive Committee minutes of evidence that the infectin control process had followed policy from the attending physician ID # 56 in Houston Physcians Dashboard dated April 2017 to Dec 2017Medical Executive Committee.

Based on observation, interview and record review the facility failed to follow their policy and AORN'S recommendation of sterilizing hinged surgical instruments open and the failure to disinfect used equipment controlling infections and communicable disease to patients and personnel.

Findings include:

Two RN's ID # 57, #58, were observed not decontaminating used wheelchair after usage with a disinfectant per policy after returning it to the PACU area. Also, there was no signage in the Post-Operative Care Area (PACU) to distiguish soiled equipment from clean equipment subsequebtly contributing to the spread of infectons.
Seven (7) out of (10) sterilized hinged surgical instruments inspected after sterile processing were found with the hinge closed allowing for imporoper cleaning and decontamination of debri held by the hinge during the sterilization.


Observed on 3/7/18 10:30 am in the PACU, 2 of 3 Post-Op RN's, ID # 57, #59 did not decontaminate used equipment with prescribed disinfectant per the facility policy after patient usage. It was observed that they returned to the unit not cleaned.

Observed in the Sterile Surgical Instrument storage area on 3/7/18 at 11:00 am while touring the area it was observed that 7 out of 10 hinged instruments were not opened durirng the sterilization process.

In an interview on 3/7/18 at 10:30 am with RN ID # 57, #59 reported the equipment should be cleaned after being usesd by a patient with a disinfectant. It is not acceptable to not clean the equipment.

In an interview on 3/7/18 at 11:00 am with RN Director of Surgical Services ID # 51 reported that the facility does follow AORN's (Association of peri/Operative Registerd Nurses) Perioperative Standards and Recommended Practices. She further reported that it was not acceptable for the RN ID #57 and #59 to return the contaminated wheelchair back into the PACU area without cleaning the equipment. That is the facility policy, and since there is no signage to distingused soiled from dirty it becomes more important. She also reported that she can see where another nurse could take the soiled equipment and use it on another patient without cleaning it.

Record review of facility policy titled, " Disinfection of Patient Care Equipment and Medical Device INFC.33, dated 10/2015 reads:
PURPOSE: To define the responsibility for cleaning and disinfecting patient care equipment.
POLICY: All patient care equipment and medical devices will be cleaned and disinfected according to HPH policies.

General Recommendations:
All equipment used in patient care shall be kept clean and in proper working condition.
All medical equipment used for patient care "must" be cleaned and disinfected or sterilized before use on another patient.

Record review on 3/7/18 of policy titled, "Infection Prevention and Control Program, dated 01/2012 reads:
PURPOSE:
A. The purpose of the Infection Prevention & Control (IP&C) Program is to identify and minimize risks of acquiring and transmitting infection among patient, staff, licensed individual practitioners, contract employees, visitors/guests, and the community.
POLICY:
B. The facility will maintain an ongoing program designed tp prevent, identify, and manage infections and communicable disease.

Authority Statement:
... The program will be integrated into the Facility's Quality Assessment and Performance Improvement (QAPI) program through the Quality Committee, which forwards summary reports and proceedings to the Medical Executive Committee (MEC)...

Record Review of AORN's Perioperative Standards and Recommended Practices of 2013 Edition Page 522 revealed the following:
Recommendation XII

Cleaned surgical instruments should be organized for packaging in a manner to allow the sterilant to contact all exposed surfaces...

XII.c. Instruments with hinges should be opened and those with removable parts should be disassembled when placed in trays designed for sterilization...Sterilization occurs only on surfaces that have direct contact with the sterilant...

XII.c. 1. Instruments should be kept in the open and unlocked position using instrument stringers, racks, or instrument pegs designed to contain instruments...