HospitalInspections.org

Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety code portion of a recertification survey conducted on August 22-23, 2019 the surveyor finds the facility does not comply with the applicable provisions of the 2012 Edition of NFPA 101 Life Safety Code therefore the requirements of 42 CFR Subpart 485.623, Physical Plant and Environment are NOT MET.

See the life safety code deficiencies on the associated K-tags

Based on direct observations during the survey walk-through, staff interviews and document reviews during the life safety code portion of a recertification survey conducted on August 22-23, 2019 the surveyor finds the facility does not comply with the applicable provisions of the 2012 Edition of NFPA 101 Life Safety Code.

See the life safety code deficiencies on the associated K-tags.

Based on document review, and interview, it was determined that the Critical Access Hospital (CAH) failed to ensure adherence to the policy related to appropriate utilization of Immediate Use Steam Sterilization (IUSS), for controlling infections. This potentially affected the 17 eye surgery patients for the months of May 2019, June 2019, and July 2019.

Findings include:


1. The CAH's policy entitled, "Immediate Use Steam Sterilization (IUSS)," (revised date 8/2/18) was reviewed on 7/31/19 at approximately 12:00 PM and included, "Policy...7. Items removed from the autoclave after sterilization shall be removed...and immediately taken to the sterile field to reduce contamination...8. An autoclave log containing containing date, time, patient medical record number, surgeon...operator information and reason for IUSS. 9. Items sterilized are meant to be used immediately and not maintained for future use."

2. The Hospital's IUSS logs for May 2019, June 2019, and July 2019 were reviewed on 7/31/19 at approximately 11:45 AM. The logs included: May 5, 2019, the IUSS sterilizer was used 4 times to flash sterilize eye instruments tray; June 12, 2019 the IUSS was used 2 times to flash sterilize eye instrument trays and; July 12, 2019, the IUSS was used 4 times to flash sterilize eye instrument trays. The logs failed to include the time; operator information; patient medical record number; surgeon; and reason for IUSS.

3. The CAH's surgical schedules for May 2019, June 2019, and July 2019 were reviewed and included: May 5 2019, there were 6 surgical cases of cataract (clouding of the eye lens) extraction (removal) with intraocular lens implants (artificial lenses): June 12, 2019 included 5 cases of cataract extraction with intraocular lens implants; July 17, 2019 included 5 cases of cataract extraction with intraocular lens implants.

4. During an interview on 7/31/19 at approximately 12:10 PM, the Critical Access Hospital's Certified Surgical Technician (E #3) stated, "We get 3 trays (eye) each month and I sterilize all of the eye instruments when they are received. Then I sterilize the trays after they are used so we can do the rest of the scheduled surgeries." This shows lack of adherence regarding the requirement to take items immediately to the sterile field after removal from the autoclave.

5. During an interview on 7/31/19 at approximately 12:10 PM, the Critical Access Hospital's Surgery Director (E #2) stated, "The eye surgery trays are not ours, and we have 3 trays delivered once a month, from the product representative, for our eye surgery cases. So if we have more than 3 cases, we use the immediate use sterilizer. That is all our product representative will send us."