HospitalInspections.org

Based on observation, staff interview and record review, the hospital failed to provide patients with a copy of their rights upon admission. This failed practice does not give patients the opportunity to understand or be aware of their rights while receiving services at the hospital. The findings are:

A. On 08/27/15 at 10:00 am during interview, Emergency Department Registration Clerk #1 stated, "We do not provide all patients with a copy of the patient's rights; if they have been here before, they will not be given a copy as they have received a copy of it previously. If a year has elapsed from their last admission, they then receive a copy."

B. On 08/27/15 at 10:30 am during interview, the Outpatient Manager stated that the hospital does not provide returning patients with a copy of their rights when they are registering for outpatient services. She added, "We update patient rights every six months in our system."

C. On 08/27/15 at 10:45 am during interview, Registration Clerk #1 at the main entrance of the hospital stated, "We do not provide patient rights information to patients if they have been seen before by the hospital. We update patients with information yearly in the electronic record."

D. On 08/27/15 at 11:00 am during interview, the Director of Nursing stated that she was not aware that each patient visit should be seen as an individual case, and that therefore patients should be provided a copy of their rights for each visit.

Based on observation, staff interview and record review, the facility failed to provide and maintain a clean and sanitary environment in the operating rooms and procedural room by not following standards of practice for terminal cleaning (a cleaning method used in healthcare environments to control the spread of infections) regarding thoroughness of cleaning and the use of protective gear. This deficient practice resulted in the likelihood for germs to be spread from one patient to the next, thereby increasing the risk for patients to contract a hospital-acquired infection during surgery. The findings are:

A. On 08/26/15 at 12:45 pm, during observation of the hospital operating room, OR (operating room) Tech #1, #2, and #3 performed a terminal cleaning of the operating rooms. All three OR techs were wearing a scrub uniform and gloves, but no masks or eye coverings. The operating room techs cleaned the surfaces in the OR with LpH, a one-step germicidal detergent. The OR techs next started to clean the walls and floor. After the floor was cleaned, OR Tech #1 brought a ladder into the room and started to clean the OR lights and OR Tech #3 started to clean the ceiling.

B. On 08/26/15 at 12:45 pm, during interview OR Tech #1 was asked when and how terminal cleaning is completed. OR Tech #1 stated, "We clean from ceiling to floor and terminal cleaning is done daily unless we get busy and sometimes terminal cleaning does not get done."

C. On 08/27/15 at 7:30 am, during interview the Infection Control Nurse (ICN) was asked when the OR suites are cleaned. She stated that the OR staff members (i.e., the OR techs) complete a terminal cleaning of the OR suites daily. The ICN stated that she had not gone to the OR to observe terminal cleaning.

D. On 08/26/15 at 2:45 pm, during interview the Supervisor of Housekeeping stated that the OR suites are terminally cleaned once a week by the OR staff. She stated that the housekeeping staff has not cleaned the ORs for about 3 years. When asked if she had observed the OR staff doing the terminal cleaning in the OR, she stated "No." When asked if she had trained the OR staff on terminal cleaning, she stated "No."

E. Record review of the hospital policy effective date 07/30/09 titled "[name of facility] - Surgical Services Housekeeping Procedures" indicated the following: "Housekeeping procedures include cleaning and disinfection of the surgical suite and disposal of soiled linen and solid wastes. These procedures are performed by Environmental Services personnel assigned to the Surgical Services Department. Terminal cleaning of operating room at end of schedule:
a. Furniture is thoroughly scrubbed and disinfectant using effective mechanical friction. Table wheels and casters are cleaned and inspected for debris. Surgical lights and tracks are cleaned. All wall-mounted equipment, view boxes, etc., are cleaned with a detergent germicide solution and disposable wipes.
b. Kick buckets are thoroughly cleaned with detergent germicide, new liner is inserted.
c. Walls are cleaned as necessary.
d. Cabinet doors and handles are cleaned.
e. Entire floor space is mopped with detergent germicide."

F. Record review of the Safety Data Sheet LpH One-Step Germicidal Detergent revealed the following protocol: "Personal Protection: When handling items soiled with blood or body fluids, use disposable impervious gloves, gowns, masks and eye coverings..."