HospitalInspections.org

Based on observation and interview, the facility failed to maintain its surgical environment and assure the safety and well-being of patients in the restricted surgery areas.

Findings:

1. During an observation on 2-18-13 at 1720 hours, the following condition was observed in the restricted surgery area: 18 ceiling tiles and supporting grid in the Clean Utility sterile storage were observed with a significant accumulation of dark dust and particulate material present at the edge between the tiles and the supporting grid. An additional 18 ceiling tiles and supporting grid were observed with accumulated dark dust and particulate matter in the restricted corridor outside of the operating rooms and clean utility storage. 3 ceiling tiles were observed with a narrow gap open to the space above the ceiling in the Clean Utility and corridor areas.

2. During an interview on 2-18-13 at 1720 hours, staff A4, A7 and A8 confirmed the accumulated dust and ceiling tile gaps.

Based upon document review and interview, the medical staff and Quality Assurance (QA) program failed to implement a corrective action in response to unsatisfactory response rates in 2010 and 2011 by surgeons reporting post-operative infections through the Infection Control (IC) program.

Findings:

1. The KCH Infection Control Plan 2012 (approved 6-12) indicated the following regarding ongoing surgeon compliance with reporting post-operative infections: "Post op letter Compliance: 75% (Goal not met for 2010 or 2011 ...)."

2. Documentation of surgeon reporting compliance dated 4-19-12 indicated that 11 of 28 physicians failed to exceed 70% compliance with required reporting and 12 of 28 physicians were 100% compliant in 2011.

3. On 2-19-13 at 0930 hours, staff A3 and A4 were requested to provide documentation of a Medical Executive Committee (MEC) or QA committee action in response to the deficient practice and none was provided prior to exit.

4. During an interview on 2-19-13 at 1015 hours, staff A3 confirmed that the MEC minutes failed to document an action in response to the problem identified through the IC program.