HospitalInspections.org

Based on review of facility documents, observation and interview, the facility failed to ensure that the premises were clean and orderly.

Findings included:

Facility policy titled "Patient Safety Plan" stated in part, "The Patient Safety Plan will improve patient safety and reduce risk to patients through an environment that encourages:
a) Integration of safety priorities into all relevant organization processes, functions, services, departments and programs ..."

Facility policy titled "Bloodborne pathogens exposure control plan" stated in part, "Contaminated Sharps Discarding and Containment: Contaminated sharps are discarded immediately or as soon as feasible in containers that are closable, puncture resistant, leak proof on sides and bottom, and biohazard labeled or color-coded.
During use, containers for contaminated sharps are easily accessible to personnel; located as close as is feasible to the immediate area where sharps are being used or can be reasonably anticipated to be found (e.g., laundries); maintained upright throughout use; are not allowed to overfill; and replaced routinely ...
Housekeeping: Employers shall ensure that the worksite is maintained in a clean and sanitary condition."

Facility policy related to central supply stated in part, "Central Supply was established to centralize the distribution and control of sterile and nonsterile items used in all clinical areas of the hospital and Crane Rural Health Cinic ... The goal of Central Supply is no only [sic] to provide and render services, but also to maintain quality aseptic control procedures in a continuing effort to prevent and control the spread of infection."
Facility "Patient Bill of Rights" stated in part, "The patient has the right to receive care in a safe setting."

Tour of the facility on the afternoon of 8/15/16 revealed the following:
· At 3:00 pm, the Mechanical Room unlocked, leading to second floor. The CNO stated, "Should be locked."
· Drain Cleaner in the soiled utility room, unlocked and unattended on the patient corridor.
· Shower room had a portable oxygen tank sitting on the floor unsecured.
· Patient room 112 had a layer of dust on the over-bed light and the biohazard sharp container was overflowing
· Patient room 110 had a layer of dust on the TV and the biohazard sharp container was overflowing
· Patient rooms 108 and 106 had a layer of dust on the TV and overhead light
· The Phlebotomy room had overflowing sharps containers.
· Unlocked, unmonitored, Janitors Closet had Stride Citrus cleaner sitting on the floor
· ER blanket warmer extremely hot to the touch, not monitoring temps and a Mayo stand was held together with tape.
· In the Central Supply room, there were 20 outside shipping boxes used to store supplies which allow for environmental elements, such as bugs, to enter
· Dead roach on the floor in the OR [operating room] corridor
· Nourishment room had a hole in the ceiling that was not sealed
· Patient corridor had a security camera in the ceiling that had a hole that was not sealed
· Endoscope sterile processing room had a tube and electrical outlet piping with three holes in the ceiling that were unsealed
· Kitchen had holes in the ceiling from pipes, electrical outlets and a pot and pan hanging rack with four holes in the ceiling that were unsealed
· The dishwasher room had ten holes in the ceiling that were unsealed
· Five overhead lights had bugs in them
· On the recovery room crash cart, were three 18 gauge catheters that expired on 05/16
· In the OR suite, were two 18 gauge catheters that expired on 02/2015 and one that expired on 05/16
· In the OR corridor, there was one chlora-prep one-step with tint that expired on 03/16
· In radiology, there was one suction tubing package that was opened
· In the phlebotomy room, there was one bag of red-top pediatric tubes that expired on 06/16 and one bag of green top pediatric tubes that expired on 04/16
The above was verified on the tour with the Chief Operating Officer on the afternoon of 8/15/16.

Based on a tour of the facility, review of facility policies, and staff interview, the facility failed to ensure that unusable drugs were not available for patient use. Two opened multi-dose medication vials did not have the dates they were opened and were available for patient and staff use.
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Findings were:

"Centers for Disease Control and Prevention Injection Safety Multi-dose vials," states in part, "Medication vials should always be discarded whenever sterility is compromised or questionable. In addition, the United States Pharmacopeia (USP) General Chapter 797 recommends the following for multi-dose vials of sterile pharmaceuticals: · If a multi-dose has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.

If a multi-dose vial has not been opened or accessed (e.g., needle-punctured), it should be discarded according to the manufacturer's expiration date. The manufacturer's expiration date refers to the date after which an unopened multi-dose vial should not be used. The beyond-use-date refers to the date after which an opened multi-dose vial should not be used. The beyond-use-date should never exceed the manufacturer's original expiration date."
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Facility document entitled, "Multi-Dose Protocol," stated in part, "Multi-dose vials are acceptable for usage under the following guidelines so that the usage of reusable vials can be monitored. 5. The vial will be discarded after thirty (30) days if not utilized."
During a tour of the medication room on the afternoon of 08/15/2016, the following multi-dose drug were available for immediate use.

· Purified Protein Derivative (PPD) multi-dose vial did not have date it was opened.
· Dexamethasone 10 milliliter vial did not have date it was opened.
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The above findings were confirmed on 08/15/2016 by Chief Executive Officer and the Chief Nursing Officer.

Based on personnel file review and interview it was determined that the Infection Control Officer did not have up to date training/education on principles and methods for infection prevention and control.

Findings were:

Review of the facility's infection control officer (ICO) personnel file, it was determined that the ICO did not have documents that she participated in infection control training and education since 2009. On December 4th, 2009 she attended TDSHS Continuing Education Services 4th Annual West Texas Infection Control Conference. She received 9.5 contact hours at that time. No other documents of Infection Control training/education were available.

In an interview with the ICO, she reported that she performs infection control training for a week annually for hospital staff.

In an interview with the ICO, she confirmed the above findings on the afternoon of 08/16/2016

Based on record review and interview the facility's surgeons failed to perform an assessment of the health status of pre-surgical patients when history and physicals were not updated on the day of surgery for (3) of (3) surgical patient's medical records reviewed. (Patients #19, 20 and 21)

Findings include:

Review of Patients #19's, 20's and 21's surgical medical records revealed the Surgeon did not review and update the patient's History and Physical on the day of surgery.

During an interview on 8/16/16 at 3:00 p.m., in the conference room, Staff #3, Infection Control Nurse, stated, "The physician does not update the history and physical on the day of surgery."

During an interview on 8/16/16 at 3:30 p.m., in the conference room, Staff #14, Chief Nursing Officer confirmed the finding.

Based on interview and record review the facility failed to develop and implement a system for the monitoring of post-operative patients for possible hospital acquired infections and did not track Flashed( a modification of conventional steam sterilization, immediate use sterilization) instruments.

Findings include:

During an interview on 8/16/16 at 10:15 a.m. in the facility's conference room Staff #3, Infection Control, Quality Assurance Nurse, when asked if the facility had a policy for the monitoring of post-operative surgical infections, Staff #3 stated, "Not that I know of...The only way I can know if a patient has an infection is if they follow up with their local physician at the clinic. We only hear about it if there is a problem ....It is difficult to get information for the out of town patients."
When asked if the facility had an immediate use sterilization log, Staff #3 stated, "I don't know."

Review of the facility provided Sterilizing processing documents reflected:

On 1/22/15 #105 Flash, #106 Flash
On 3/19/15 #108 flash, #110 Flash
On 5/21/15 #117 Flash fail, #118 Flash
On 7/23/15 #129 Flash, #130 flash
On 10/22/15 #147 Flash

No sterilization processing documents were available for December 2015.

Review of the "Centers for Disease Control (CDC) Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008 ... Flash sterilization should not be used for reasons of convenience, as an alternative to purchasing additional instrument sets, or to save time... Because of the potential for serious infections... recordkeeping (i.e., load identification, patient's name/hospital identifier, and biological indicator result) is essential for epidemiological tracking (e.g., of surgical site infection, tracing results of biological indicators to patients who received the item to document sterility), and for an assessment of the reliability of the sterilization process....19. Quality Control...d. Include the following in a quality control program for sterilized items...traceability of load contents..."

During an interview on 8/15/16 at 4:15 p.m. in the facility's conference room Staff#14, Chief Nursing Officer stated, "The facility uses the CDC for infection control guidelines..."

The surveyor requested the flash (Immediate Use Sterilization) log. The facility did not provide the log prior to the exit.