HospitalInspections.org

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Based on observation, interview, and document review, the hospital failed to meet the requirements of the Life Safety Code of the National Fire Protection Association (NFPA), 2012 edition.

Failure to ensure a fire-safe environment of hospital hazards risks patient, visitor, and staff safety.

Findings included:

Refer to deficiencies written on Life Safety Code Inspection Report found at shell M8T021.
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Item #1 Restraint Face to Face Assessment

Based on interview, record review, and review of the hospital policy and procedure, the hospital failed to ensure that patients placed in restraints or seclusion received a face-to-face assessment within one hour by a physician or licensed independent practitioner as directed by hospital policy for 1 of 3 patients in violent restraint reviewed (Patient #902).

Failure to perform the required face-to-face evaluation to determine whether the patient actually meets the specific criteria for restraint or seclusion places patients at risk of harm, injury, or other decline in status.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Restraint and Seclusion Policy," PolicyStat ID 12719679, last approved 12/22, showed the following:

a. A face to face evaluation by provider, LP, or trained RN within 1 hour.

b. The face to face documentation for violent restraints includes:

i. The patient's immediate situation

ii. The patient's reaction to the intervention.

iii. The patient's medical and behavioral condition.

iv. The need to continue or terminate the restraint or seclusion.

c. If the face to face is done by the RN, he/she must consult the provider as soon as possible after the completion of the evaluation.

2. On 02/23/23 at 8:30 AM, Surveyor #9 and Emergency Services Manager (Staff #906) reviewed the medical record for Patient #902 who was placed in violent restraints on 11/18/22 at 10:10 PM. Surveyor #9 found no evidence of a documented face to face evaluation as directed by hospital policy.

3. At the time of the review, Staff #906 verified there was no documentation of a face to face in the medical record.

Item #2 Restraint Orders

Based on interview, record review, and review of hospital policy and procedures, the hospital failed to ensure that there was an order for restraints for 2 out of 4 restraint episodes reviewed (Patient #903).

Failure to follow established procedures for restraints risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Restraint and Seclusion Policy," PolicyStat ID 12719679, last approved 12/22, showed the following:

a. If the provider is not available at the time of the assessment indicating need for restraint, a registered nurse without an order may initiate restraint.

b. In this case, an order will be obtained from the provider immediately but no longer than 1 hour after initiation of violent restraint.

c. As soon as possible after initiation of non-violent restraint.

2. On 02/23/23 at 9:00 AM, Surveyor #9 and Emergency Services Manager (Staff #906) reviewed the medical record for Patient #903. On 12/18/22 at 6:15 AM, the patient became agitated and was placed in violent restraints. Surveyor #9 found no evidence of an order for this restraint episode. On 12/20/22 at 9:19 AM, the patient was placed in soft restraints for being combative to staff. Surveyor #9 found no evidence of an order for this restraint episode.

3. At the time of the review, Staff #906 verified the missing restraint orders as required by policy.

Item #3 Surgical Attire

Based on observation, interview, and document review of the hospital's policy, 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.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Surgical Attire," Policy Stat 8943438, last approved 12/20, showed the following:

a. The restricted area of the OR includes the procedure room and center core.

b. People in the restricted area are required to wear full surgical attire and cover all head and facial hair, including sideburns, beards, and necklines.

2. On 02/22/23 at 9:10 AM, Surveyor #9 and Surgical Services Manager (Staff #910), Program Manager Regulatory Compliance (Staff #904), and Infection Control Nurse (Staff #913) inspected the surgical area. Surveyor #9 observed a medical provider (Staff #914) in the restricted area of the operating room with beard and sideburns uncovered.

3. At the time of the observation, Staff #910 verified the observation.

4. On 02/22/23 at 11:30 AM, Surveyor #9 and Infection Control Nurse (Staff #913) were observing a set up for a surgical case. The surgeon (Staff #915) entered the operating room with beard and sideburns uncovered. There was a beard cover in place below their chin.

5. At the time of the observation, Staff #913 verified the observation.

Item #4 Sterile Field
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Based on observation and interview, the hospital failed to ensure staff followed national standard infection control practices to maintain the integrity of the sterile field in the surgical area.

Failure to follow national standard infection control practices to maintain a sterile field risks patient infection and hospital acquired infections.

Reference: AORN (Association of periOperative Registered Nurses) Standard 7. Moving Around a Sterile Field. Scrubbed team members should keep their hands and arms above waist level at all times, not fold their arms with their hands positioned in the axillary area, not turn their backs on the sterile field, and avoid changing levels, and be seated only when the entire procedure will be performed at that level.

Findings included:

1. On 02/22/23 at 10:55 AM, Surveyor #9 and Infection Control Nurse (Staff #913) were observing a set up for a surgical case. Surveyor #9 observed the following:

a. Certified Registered Nurse Anesthetist (Staff #917) placed disposable electrodes on the electrocardiogram (EKG) leads in preparation to monitor the patient. The leads and electrodes were placed over the head of the operating room table and were touching the floor.

b. After scrubbing, donning sterile attire, and preparing the instruments, Scrub Technician (Staff #916) sat on a stool with their arms folded while waiting for the patient to be positioned on the operating room table. Staff #916 then stood up when the surgeon entered the operating room.

2. At the time of the observations, Staff #913 verified the observations and spoke with Staff #917 who changed the EKG electrodes.

3. On 02/22/23 at 4:00 PM, Surveyor #9 interviewed Surgical Services Manager (Staff #910) regarding procedures for maintaining the sterile field in the operating room. Staff #910 stated that they were not aware of any policies, or the standard, however, did follow AORN standards.
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Based on interview, record review, and review of the hospital's policy and procedure, the hospital failed to ensure that staff members completed and documented vital signs for obstetrical patients receiving magnesium sulfate therapy for seizure prevention for 1 of 1 patient reviewed (Patient #909).

Failure to perform vital sign assessments risks harm related to delayed recognition of condition warranting immediate care.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Hypertensive Disorders of Pregnancy: Including Gestational Hypertension, Chronic Hypertension, Preeclampsia, and Eclampsia," PolicyStat ID 11317724, last approved 03/22, showed that for patients on Magnesium sulfate with severe features of preeclampsia, vital signs including blood pressure, pulse, respirations, and pulse oximeter are to be assessed hourly for the first 24 hours after delivery.

2. On 02/22/23 at 12:00 PM, Surveyor #9 and Family Birth Center Manager (Staff #911) reviewed the medical record of Patient #909. The review showed the patient delivered by cesarean section on 02/07/23 at 06:19 AM. The patient had a diagnosis of severe preeclampsia and was receiving Magnesium sulfate intravenously for seizure prevention. Surveyor #9 found no evidence of blood pressure assessments on 02/07/23 between 12:00 PM and 4:00 PM (a period of 4 hours) and 4:00 PM and 8:00 PM (a period of 4 hours). Surveyor #9 found no evidence of a respiratory assessment between 4:55 PM and 8:00 PM (a period of approximately 3 hours).

3. At the time of the review, Staff #911 verified the missing assessment documentation.
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Item #1 Pain assessments and reassessments

Based on interview, record review, and review of policy and procedure, the hospital failed to ensure staff members completed and documented pain assessments and reassessments for each pain management intervention for 5 of 5 patients reviewed (Patients #907, #908, #909, #910 and #911).

Failure to assess and reassess a patient's pain risks inconsistent, inadequate, or delayed relief of pain and risks patient harm related to delayed recognition of adverse effects of pain medication.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Pain Management Policy," PolicyStat ID 7177265, last approved 11/19, showed the following:

a. The patient's pain intensity is reassessed after pharmacologic interventions.

b. In general, reassessment following an intravenous pharmacologic intervention will be about 20 minutes or about 60-90 minutes for an oral agent.

c. Reassessment of patients who appear to be "asleep" cannot be done by observation alone.

2. On 02/21/23 between 1:00 PM and 1:30 PM, Surveyor #9 and Registered Nurse (Staff #912) reviewed the medical record of Patient #910 who was admitted on 02/19/23 for a closed reduction of a fractured femur. The review showed on 02/21/23 at 7:41 PM, the patient received Oxycodone (an opioid pain medication) 5 milligrams 1 tablet orally for a pain score of 6. Surveyor #9 was unable to find documentation of a pain reassessment following the intervention.

3. At the time of the review, Staff #912 verified the documentation.

4. On 02/21/23 between 1:30 PM and 2:00 PM, Surveyor #9 and Registered Nurse (Staff #912) reviewed the medical record of Patient #911 who was admitted on 02/19/23 for surgery following a fractured hip. The review showed on 02/21/23 at 1:47 AM, the patient received Morphine (an opioid pain medication) 2 milligrams intravenously for a pain score of 6. Surveyor #9 was unable to find documentation of a pain reassessment following the intervention.

5. At the time of the review, Staff #912 verified the documentation.

6. On 02/22/23 at 10:00 AM, Surveyor #9 and Family Birth Center Manager (Staff #911) reviewed the medical record of Patient #908 who had a vaginal delivery on 02/21/23 at 6:07 PM. The review showed the following:

a. On 02/22/23 at 2:48 AM, the patient received Ibuprofen (an anti-inflammatory pain medication) 800 milligrams orally for a pain score of 3. Surveyor #9 was unable to find documentation of a pain reassessment following the intervention.

b. On 02/22/23 at 5:30 AM, the patient received Hydrocodone-Acetaminophen (an opioid and non-opioid pain medication) 5-325 milligrams 1 tablet orally for a pain score of 7. Surveyor #9 was unable to find documentation of a pain reassessment following the intervention.

7. At the time of the review, Staff #911 verified the documentation.

8. On 02/22/23 at 10:30 AM, Surveyor #9 and Family Birth Center Manager (Staff #911) reviewed the medical record of Patient #907 who had a cesarean section on 02/06/23 at 11:33 AM. The review showed the following:

a. On 02/06/23 at 6:16 PM, the patient received Toradol (an anti-inflammatory used to treat pain) 30 milligrams intravenously for a pain score of 6. Surveyor #9 was unable to find documentation of a pain reassessment following the intervention.

b. On 02/06/23 at 9:18 PM, the patient received Oxycodone-Acetaminophen (an opioid and non-opioid pain medication) 5-325 milligrams 1 tablet orally for a pain score of 4. Surveyor #9 was unable to find documentation of a pain reassessment following the intervention.

c. On 02/07/23 at 1:28 AM, the patient received Oxycodone-Acetaminophen 5-325 milligrams 2 tablets orally for a pain score of 4. Surveyor #9 was unable to find documentation of a pain reassessment following the intervention.

d. On 02/07/23 at 5:32 PM, the patient received Oxycodone (an opioid pain medication) 5 milligrams orally for a pain score of 5. Surveyor #9 was unable to find documentation of a pain reassessment following the intervention.

e. On 02/07/23 at 6:56 PM, the patient received Oxycodone-Acetaminophen 5-325 milligrams 2 tablets orally and Ibuprofen 800 milligrams orally. Surveyor #9 was unable to find documentation of a pain assessment prior to administration of the medications.

f. On 02/07/23 at 11:01 PM, the patient received Oxycodone-Acetaminophen 5-325 milligrams 1 tablet orally and Oxycodone 5 milligrams orally for a pain score of 3. Surveyor #9 was unable to find documentation of a pain reassessment following the intervention.

g. On 02/07/23 at 1:32 AM, the patient received Ibuprofen 800 milligrams orally for a pain score of 4. Surveyor #9 was unable to find documentation of a pain reassessment following the intervention.

h. On 02/07/23 at 4:35 AM, the patient received Oxycodone-Acetaminophen 5-325 milligrams 1 tablet orally for a pain score of 4. Surveyor #9 was unable to find documentation of a pain reassessment following the intervention.

9. At the time of the review, Staff # 911 verified the documentation.

10. On 02/22/23 at 12:00 PM, Surveyor #9 and Family Birth Center Manager (Staff #911) reviewed the medical record of Patient #909 who had a cesarean section on 02/07/23 at 6:19 AM. The review showed the following:

a. On 02/07/23 at 5:45 PM, the patient received Hydromorphone (an opioid pain medication) 2 milligram tablet orally for a pain score of 7. Surveyor #9 was unable to find documentation of a pain reassessment following the intervention.

b. On 02/07/23 at 9:09 PM, the patient received Toradol 15 milligrams intravenously for a pain score of 6. Surveyor #9 was unable to find documentation of a pain reassessment following the intervention.

c. On 02/08/23 at 3:33 AM, the patient received Toradol 15 milligrams intravenously. Surveyor #9 was unable to find documentation of a pain assessment prior to administration or a pain reassessment following the intervention.

d. On 02/08/23 at 8:21 AM, the patient received Oxycodone-Acetaminophen 5-325 milligrams 1 tablet orally for a pain score of 7. Surveyor #9 was unable to find documentation of a pain reassessment following the intervention.

e. On 02/08/23 at 8:14 PM, the patient received Ibuprofen 800 milligrams orally for a pain score of 4. Surveyor #9 was unable to find documentation of a pain reassessment following the intervention.

f. On 02/08/23 at 8:15 PM, the patient received Oxycodone-Acetaminophen 5-325 milligrams 1 tablet orally for a pain score of 4. Surveyor #9 was unable to find documentation of a pain reassessment following the intervention.

g. On 02/09/23 at 2:38 AM. the patient received Oxycodone-Acetaminophen 5-325 milligrams 1 tablet orally for a pain score of 4. Surveyor #9 was unable to find documentation of a pain reassessment following the intervention.

h. On 02/09/23 at 9:59 AM. the patient received Oxycodone-Acetaminophen 5-325 milligrams 1 tablet orally for a pain score of 4. Surveyor #9 was unable to find documentation of a pain reassessment following the intervention.

11. At the time of the review, Staff # 911 verified the documentation.

Item #2 Blood Administration

Based on interview, record review, and document review of the hospital's policy and procedures, the hospital failed to ensure staff followed its policy and procedure for blood product transfusions for 3 of 3 patients reviewed (Patients #912, #913, and #914).

Failure to follow blood transfusion procedures according to acceptable standards of practice places patients at risk for transfusion reactions and complications.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Blood and Blood Components Administration Policy," PolicyStat ID 1261611, last approved 12/22, showed the following:

a. Just prior to hanging blood, take baseline vitals and record in the electronic health record.

b. Once the infusion begins, take and document vital signs at the following intervals - measured from the time the blood first enters the patient's body: 15 minutes, approximately 1 hour, 2 hours, 3 hours, and 4 hours after the start of the transfusion, anytime throughout the transfusion if a transfusion reaction is suspected, immediately upon the completion of the transfusion, and approximately 1 hour after the transfusion is completed (inpatients only).

c. Vital signs include temperature, pulse, respiratory rate, and blood pressure.

d. When taking vitals, perform a lung and skin exam and ask the patient how they are feeling.

e. Document on the flowsheet Transfusion Reaction Yes or No.

2. On 12/24/23 between 11:15 AM and 12:00 PM Surveyor #9 and Acute Care Manager (Staff #909) reviewed the medical record of 3 patients who received blood transfusions. The review showed the following:

a. Patient #912 received a blood transfusion that was initiated on 01/16/23 at 10:06 PM and finished on 01/17/23 at 2:14 AM. Respirations were documented on 01/16/23 at 10:15 PM and 01/17/23 at 2:14 AM (a period of approximately 4 hours).

b. Patient #913 received a blood transfusion that was initiated on 02/16/23 at 7:31 PM and finished on 02/16/23 at 10:15 PM. Vital signs were documented at 6:00 PM (approximately 1.5 hours prior to the initiation). Vital signs were documented at the end of the transfusion at 10:15 PM and a blood pressure and pulse documented at 12:00 AM (a period of approximately 2 hours) after the transfusion ended.

c. Patient #914 received a blood transfusion that was initiated on 02/11/23 at 8:45 AM and finished on 02/11/23 at 11:45 AM. Vital signs were documented at 7:28 AM (approximately 1 hour 15 minutes prior to the initiation). Surveyor #9 was unable to find any documentation of a transfusion reaction.

3. At the time of the review, Staff #909 verified the missing vital signs and transfusion reaction documentation.
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Item #1 Endoscope storage

Based on document review, observation, and interview, the Critical Access Hospital failed to ensure that staff stored reprocessed flexible endoscopes in a manner to prevent contamination.

Failure to prevent contamination of reprocessed flexible endoscopes places patients at increased risk of exposure to infection.

References: Society of Gastroenterology Nurses and Associates, Inc. (SGNA) Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes (2012). Endoscope Reprocessing Protocol 8 STORAGE a. Endoscopes should be stored in a manner that will protect is from contamination; a storage area should be clean ... discouraging any microbial contamination.

Custom Ultrasonics, Inc. Endoscope Storage Cabinet Model 20000 Operator's Manual, revision 08232021. Daily Cleaning 1. The stainless steel drip plate must be cleaned and sanitized daily; clean both the interior and exterior of the Storage Cabinet on a routine basis using a damp lint free cloth and standard, hospital grade, non-abrasive surface cleaner/disinfectant.

Olympus EVIS EXERA III Reprocessing Manual Chapter 8 Storage and Disposal: Establish a local policy regarding the method and frequency of cleaning and disinfecting the endoscope storage cabinet; Be sure that the endoscope cabinet is properly maintained, clean, dry, and well ventilated ... hang endoscope in a storage cabinet with the distal end hanging freely.

Findings included:

1. Document review of the hospital's policy titled, "Flexible Endoscopes IC Standards High Level Disinfection," PolicyStat ID: 11577389, approved 05/22, showed that endoscopes should be stored in a manner that will protect the scope from contamination; scopes must be stored in an area that keeps them dry and free of dust and microbial contamination. The scopes should hang freely to prevent impact and contamination.

2. On 02/21/23 between 11:30 AM and 12:10 AM, during a tour of the Sterile Processing Department (SPD), Surveyor #6 observed 2 flexible endoscope storage cabinets. The observation showed that several endoscopes (at least 3) were in contact with adjacent endoscopes with the distal end coiled around another endoscope. One of the endoscopes was in contact with the galvanized steel cover of an electrical box on the inside of the cabinet.

3. At the time of the observation, Surveyor #6 interviewed the Perioperative Manger (Staff #604) about the hospital's policies for endoscope storage and storage cabinet cleaning/disinfection. Staff #604 stated that flexible endoscopes should hang vertically after reprocessing but she did not know when or how often the endoscope storage cabinet was cleaned or disinfected.

4. On 02/24/23 at 11:15 AM, Staff #604 confirmed that the endoscope storage cabinets in the SPD did not have a schedule for cleaning/disinfection.

Item #2 Expired supplies

Based on interview and observation, the hospital failed to develop and implement a quality control system to prevent the use of patient care supplies that exceeded the manufacturer's expiration date.

Failure to monitor and establish a systematic process for ensuring patient care supplies do not exceed the manufacturer's expiration date risks deteriorated or potentially contaminated supplies being available for patient care.

Findings included:

1. On 02/21/23 between 10:20 AM and 11:45 AM, Surveyor #9 and Emergency Services Manager (Staff #906) inspected the Emergency Department. The observation showed the following:

a. One Airlife filter (for a ventilator) with a manufacturer's expiration date of 12/22.

b. One 4.5 laryngeal airway with a manufacturer's expiration date of 06/22.

2. At the time of the observation, Staff #906 verified the expired items and removed them from patient use.

3. On 02/21/23 between 12:15 PM and 12:45 PM, Surveyor #9 and Program Manager Regulatory Compliance (Staff #905) inspected the Acute Care Unit. The observation showed the following in a cabinet in the medication room:

a. One viral transport media with a manufacturer's expiration date of 11/22.

b. Three 23-gauge blood collection sets with a manufacturer's expiration date of 09/21.

c. One arterial blood sampler with a manufacturer's expiration date of 11/20.

d. One 25-gauge needle with a manufacturer's expiration date of 09/22.

e. One 27-gauge needle with a manufacturer's expiration date of 12/22.

4. At the time of the observation, Staff #905 verified the expired items and removed them from patient use.

5. On 02/21/23 between 3:10 PM and 4:00 PM, Surveyor #9 and Clinical Coordinator (Staff #907) inspected the Family Birth Center. The observation showed the following in the epidural cart:

a. Two Packages of Chloraprep swab sticks with a manufacturer's expiration date of 09/22.

b. Two 16-gauge Insyte intravenous catheters with a manufacturer's expiration date of 06/22.

c. Two 18-gauge Insyte intravenous catheters with a manufacturer's expiration date of 12/22.

d. One 20-gauge Insyte intravenous with a manufacturer's expiration date of 11/22.

e. Two Shiley intubating stylets with a manufacturer's expiration date of 03/22.

f. One Frova intubating transducer with a manufacturer's expiration date of 08/21.

g. One 2.5 endotracheal tube with a manufacturer's expiration date of 10/21.

h. One 3.5 endotracheal tube with a manufacturer's expiration date of 02/22.

i. One 4.0 endotracheal tube with a manufacturer's expiration date of 11/22.

j. One 4.5 endotracheal tube with a manufacturer's expiration date of 08/22.

k. One 5.0 endotracheal tube with a manufacturer's expiration date of 04/22.

l. One 5.5 endotracheal tube with a manufacturer's expiration date of 02/22.

m. One 6.0 endotracheal tube with a manufacturer's expiration date of 09/22.

n. One 6.5 endotracheal tube with a manufacturer's expiration date of 09/22.

o. One 8.0 endotracheal tube with a manufacturer's expiration date of 12/22.

6. At the time of the observation, Staff #907 verified the expired items and removed them from patient use. Surveyor #9 interviewed Staff #907 as to the process for checking the cart. Staff #907 stated the nursing staff was responsible to check the cart however would verify with another nurse. Registered Nurse (Staff #908) stated the nurses responsibility was for restocking the cart, not checking for expired items.

7. On 02/22/23 between 8:20 AM and 10:00 AM, Surveyor #9 and Surgical Services Manager (Staff #910) and Program Manager Regulatory Compliance (Staff #905) inspected the Operative area. The observation showed the following:

a. One endotracheal introducer with a manufacturer's expiration date of 01/23.

b. Two 24-gauge Insyte intravenous catheters with a manufacturer's expiration date of 12/22.

8. At the time of the observation, Staff #910 verified the expired items and removed them from patient use.
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Item #1 Decontamination area for reprocessing patient care instruments

Based on document review, observation, and interview, the Critical Access Hospital failed to maintain the Sterile Processing Department (SPD) decontamination area in a condition to prevent cross-contamination and discourage growth of microorganisms.

Failure to effectively prevent cross-contamination while cleaning surgical instruments places staff at increased risk of exposure to pathogens.

Findings included:

1. Document review of the hospital's, policy titled, "Decontamination Standard #115.00," PolicyStat ID: 12833035, approved 12/22, showed that decontamination areas are to be kept clean and dry to reduce risk of infection to health care workers (HCWs) and discourage growth of microorganisms.

2. On 02/21/23 between 11:30 AM and 12:10 AM, during a tour of the Sterile Processing Department (SPD), Surveyor #6 observed gross debris in the decontamination sink and terry cloth towels on either side of the decontamination sink. Each towel was stained with what appeared to be blood. There were no dirty instruments or equipment, and no decontamination activities occurring at the time of the observation.

3. At the time of the observation, Surveyor #6 interviewed the Perioperative Manger (Staff #604) and a Sterile Processing Technician (Staff #605) about decontamination area. Staff #605 stated that the sink should have been cleaned and sanitized after the last use and that the towels are always changed at the end of each day. Staff #604 confirmed the observation that terry cloth towels provide absorbent, uncleanable surfaces that encourage microbial growth.

4. On 02/22/23 at 10:50 AM, Surveyor #6 and Staff #604 observed an Endoscope Technician (Staff #606) reprocess an Olympus colonoscope. The observation showed terry cloth towels on either side of the decontamination sink.

5. At the time of the observation Staff #604 confirmed the observation that terry cloth towels provide absorbent, uncleanable surfaces that encourage microbial growth.

Item #2 Endoscope reprocessing

Based on document review, observation, and interview, the Critical Access Hospital failed to ensure that staff prevented cross-contamination when manually cleaning endoscopes.

Failure to effectively prevent cross-contamination while cleaning endoscopes places staff at increased risk of exposure to harmful microorganisms.

References: Society of Gastroenterology Nurses and Associates, Inc. (SGNA) Standards of Infection Control in Reprocessing of Flexible Gastrointestinal Endoscopes (2012). Endoscope Reprocessing Protocol 3. Manual Cleaning: Manual cleaning of endoscopes is necessary prior to automated or manual disinfection. d. Wash all debris from the exterior of the endoscope by brushing and wiping the instrument while submerged in the detergent solution. The endoscope should be submerged in the detergent solution when performing all subsequent cleaning steps to prevent splashing of contaminated fluid and aerosolization of bioburden.

Olympus EVIS EXERA III Reprocessing Manual Chapter 5 Reprocessing the Endoscope, 5.5 Manually cleaning the endoscope and accessories: Clean the external surface - Fill a clean, large basin with the detergent solution, immerse the endoscope in the detergent solution. Brush the channels - To avoid splashing the detergent solution when the brush is pulled out from the endoscope, keep the endoscope immersed in the detergent solution while brushing.

Findings included:

1. Document review of the hospital's policy titled, "Flexible Endoscopes IC Standards High-Level Disinfection," PolicyStat ID: 11577389, approved 05/22, showed that manual cleaning is required of all instruments prior to high level disinfection or sterilization. The endoscope should be immersed in enzymatic detergent solution, the exterior of the scope washed in the detergent solution, and valves and channels brushed with the detergent solution.

2. On 02/22/23 at 10:50 AM, Surveyor #6 observed an Endoscope Technician (Staff #606) reprocess an Olympus colonoscope. The observation showed that during the manual cleaning steps, Staff #606 cleaned the scope above the level of the detergent solution and splashed the solution over the area near the sink & other surfaces.

3. At the time of the observation, Surveyor #6 interviewed Staff #606 about the manual cleaning process and identified several Olympus instructional posters directing that the endoscope should be immersed in detergent solution during manual cleaning. Staff #606 stated that she did not understand that scopes should be immersed in detergent solution during manual cleaning procedures.

Item #3 Sanitary environment

Based on observation, interview, and document review, the Critical Access Hospital failed to ensure that staff cleaned patient care areas according to hospital policy and accepted standards of practice.

Failure to comply with policies and procedures to prevent transmission of infectious organisms puts patients, staff, and visitors at increased risk from communicable diseases.

Findings included:

1. Document review of the hospital's task sheet titled, "2.2 Discharge Clean Standard Work Activity Sheet," no document number, reviewed 01/21 (CommonSpirit), showed Tasks 1 - 19 for EVS Tech to clean and disinfect a patient room following patient vacancy. Task 6 included: Raise bed to waist level and position the head and foot in a "V;" Task 9 included: The bed will be cleaned in two vertical halves beginning at the head of the bed and moving toward the footboard. Disinfect half of headboard including frame underneath. Moving down the vertical half toward the footboard, clean and disinfect the mattress top and bottom including bedframe surface. ... Using 2nd wiper clean and disinfect entire footboard surface from top to bottom including underneath. ...; Task 15 included: Perform hand hygiene and don clean gloves. Wet Mop Restroom; Task 18 included: Doff gloves. Wash and/or Sanitize hands upon exiting patient room.

2. On 02/22/23 between 11:30 AM and 12:15 PM, Surveyor #6 and the Environmental Services (EVS) Manager (Staff #607) observed an EVS Technician (Staff #608) perform a discharge cleaning of patient room #310. The observation showed:

a. The patient bed was not raised or positioned with the head and foot in a "V;"

b. A single wiping cloth was used to clean the bed;

c. The bottom surface of the mattress and the bed frame mattress deck were not disinfected at the head end of the bed;

d. Staff #608 used bare hands to mop the bathroom floor and change mop heads;

e. Staff #608 used bare hands to place toilet seat bands over the toilet and bed-side commode, put a hand on the patient bed, mopped the floor, used the computer, and exited the room without performing hand-hygiene between any of the listed tasks.

3. At 12:15 PM, Surveyor #6 interviewed Staff #608 about the hospital's expectations for discharge cleaning of patient rooms. Staff #608 stated that all staff entering or exiting a patient room should gel-in and gel-out, gloves should be changed between tasks, and beds should be made with clean, bare hands.

Item #4 Operating Room Terminal Cleaning

Based on document review, observation, and interview, the Critical Access 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.

References: Association of periOperative Registered Nurses (AORN) Guideline for Environmental Cleaning (2020) - Recommendation 2. Cleaning Procedures; 2.5 Perform cleaning activities in a methodical pattern that limits the transmission of microorganisms; progress from clean to dirty with the same cleaning material; progress from top to bottom when cleaning and damp dusting. 2.8 Always consider floors in the perioperative practice setting to be contaminated.

- Recommendation 4. OR and Procedure Rooms; 4.4 Terminally clean operating and procedure rooms each day the rooms are used. 4.4.1 Clean and disinfect the exposed surfaces of all items.

Findings included:

1. Document review of the hospital's policy titled, "Perioperative Sanitation and Cleaning Procedure," PolicyStat ID: 10936239, approved 12/21, showed that AORN Guidelines are cited as a reference; and that All Areas Perioperative Services 1. All contaminated items will be cleaned or contained immediately to prevent organisms, potential pathogens, debris, and chemicals from becoming airborne. 2. Cleaning and disinfection workflow should start with potentially least contaminated to highly contaminated areas to prevent cross contamination of clean areas. The general flow of top to bottom and clean to dirty shall be followed.

- OR Daily Terminal Cleaning. 1. Terminal cleaning/disinfection will be performed in all rooms used that day to include: OR ... Surgical lights, arms, and tracks; Fixed & ceiling mounted equipment; All furniture, equipment and walls

Document review of the hospital's task sheet titled, "3.1 Invasive Area Standard Work Activity Sheet," no document number, reviewed 01/21 (CommonSpirit), showed that all steps to terminally clean invasive procedure rooms based on AORN/AHE recommendations. Task 6. Damp High Dusting includes, All items should be damp dusted top to bottom cleanest to dirtiest following a clockwise/counterclockwise path; Any area visibly soiled with small amounts of blood, tissue, body fluids, or other potentially infectious material should be spot cleaned with a cleaner disinfectant. Task 8. Wall Cleaning and Disinfection includes, Clean the walls in an up and down motion. Task 11. Self-inspection to ensure the room has been appropriately cleaned, and to check for any corrective opportunities.

Document review of the hospital's policy titled, "Hand Hygiene Policy #931.00," PolicyStat ID: 9500538, approved 04/21, showed that cleaning hands with an alcohol-based sanitizer or washing with soap and water is required: e. Before donning gloves and after removing gloves; i. When moving from a dirty task to a clean task ...; m. After picking up items that have fallen to the floor

2. On 02/23/23 between 11:50 AM and 1:00 PM, Surveyor #6 and the Environmental Services (EVS) Manager (Staff #607) observed the terminal cleaning of Operating Room (OR) #3 by an EVS Technician (Staff #608). The observation showed the following:

a. Staff #608 performed hand-hygiene and donned gloves before removing garbage and soiled linen from OR 3, she did not remove gloves or perform hand-hygiene before resuming the terminal cleaning process, opening a cabinet drawer, and collecting clean bags;

b. Staff #608 cleaned a significant amount of blood splatter from both overhead surgical lights and did not remove gloves or perform hand-hygiene before moving to the next task;

c. Staff #608 held clean and soiled disinfectant wipes in the same hand with objects being disinfected (i.e., patient forced-air warming hose, IV pump cord) and then removed gloves, performed hand-hygiene, and donned clean gloves;

d. Staff #608 did not follow the proscribed cleaning pattern (clean to dirty, top to bottom) going from cleaning overhead lights with significant blood splatter to lightly soiled equipment on the floor, and back to the ceiling mounted boom arms of the surgical lights and wall surfaces from ceiling to floor while wearing the same gloves;

e. Surface areas were missed during disinfection process (approximately 6" square area on the top surface of a stainless-steel table, 1 side of a pharmaceutical waste bin, 3 exposed sides of a stainless-steel rolling cart drawer, approximately 6" square area on the wall surface, the lower edge of the wall surface above built-in cabinets);

f. Staff #608 removed a bin liner from a kick bucket, disinfected the bucket, and placed the used bin liner back in the bucket;

g. Staff #608 removed garbage & retrieved clean mop heads without changing gloves or performing hand-hygiene;

h. After Staff #608 stated that OR #3 was cleaned, she and the surveyor inspected the room: one of the overhead lights had 3 spots of blood splatter and there was gross debris splatter on the ceiling above the procedure lights.

3. At 1:00 PM, Surveyor #6 interviewed Staff #608 about the observations. Staff #608 stated that the hospital policy was to follow a system and described it as starting with the surgical lights, then the bed, anesthesia cart, and go around the room. Staff #608 stated that she should have double checked surfaces including the overhead lights for stains and splatter.
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Based on interview and review of the hospital's quality program, the hospital failed to implement and monitor actions taken for identified deficiencies following analysis of adverse events for 2 of 3 patient cases reviewed.

Failure to implement corrective action plans for identified problems and monitor for sustained improvement limits the hospital's ability to provide high quality clinical care and improve patient outcomes.

Findings included:

1. Document review of the "Virginia Mason Franciscan Health Divisional Quality Assessment Performance Improvement Plan," PolicyStat ID 1025925, last approved 08/21, showed the following:

a. The purpose of this plan is to support a system wide approach to monitor, assess, and improve the quality and safety of patient care.

b. Data is used to identify improvement opportunities and measure the effectiveness of safety and quality related activities.

2. On 02/24/23 at 9:00 AM, Surveyor #9 and Director of Nursing Operations (Staff #901), Patient Safety Specialist (Staff #902), and Risk Manager (Staff #903) reviewed 3 Root Cause Analysis (RCA). The review showed the following:

a. One RCA was found to have no action plan as a result of no findings.

b. Action items were developed for 2 RCA's. Surveyor #9 was unable to find any documentation of completion of the action items or any evaluation of the effectiveness of action items identified as part of the Root Cause Analysis process.

3. At the time of the review, Staff #903 confirmed that they did not know if the action plan had been completed or if there was follow up to ensure the changes were successful.
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