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Based on observation, document review, and interview the facility failed to ensure that the IV (intravenous) contrast, Isovue 370 (radiopaque dye used in radiology testing) was properly stored and locked in the Radiology Department.

During an observation tour on 10/13/2021 at 2:00 PM with Staff #16 and Staff #38 the following was observed:

CT (Cat Scan) Procedure room:

Upon entering the procedure room, it was noted that a multi-use IV contrast, Isovue 370 (a radiopaque contrast agent that contains iodine used in x-ray procedures), 500 ml (milliliters) bottle was hanging on an IV pole with IV tubing spiked into the bottle and ready for patient use. There was no beyond use date written on the bottle to determine the expiration of the contrast. A lower cabinet storing 10, 100 ml bottles of Isovue 370 was found to be unlocked.

An interview was conducted with Staff #16 on 10/13/2021 at 2:30 PM. Staff #16 was asked if the bottle of Isovue and the IV tubing was new or had it been used on a previous patient. Staff #16 could not confirm or deny if the IV tubing was new or used and stated, "It appears that the contrast had been used". Staff #16 and #38 confirmed that all contrast should be stored in a locked cabinet and not be left hanging in the procedure room or in an open cabinet.


A review of the Bracco Diagnostic Isovue 370 Insert revealed the Isovue 370 should be stored at 68-77 degrees Fahrenheit and protected from light.

Staff #16 confirmed the room was not monitored for temperature daily."


A review of the facility policy titled, "Obtaining Storage of Pharmaceuticals-DIV-MM", Policy Number:73480.1 with an approval date of 4/30/2021 was as follows:

" ...Procedures:
2) All drugs and biologicals will be stored in an environment compatible with manufacturer's recommendations ..."



Staff #16 and Staff #38 confirmed the findings.

Based on record review and interview the facility failed to have an assigned nurse or qualified individual to monitor the patients on telemetry in the Emergency Department (ED).

During an observation of the Emergency Department on 10-12-21 at 3:17PM three nurses were sitting at the nurse's station where the telemetry monitor was. There were two patients on telemetry (Telemetry in hospitals are where patients are under constant electronic monitoring of the heart rate, blood pressure, heart rhythm, and oxygen levels.) An ambulance came in with a patient and all the nurses left the nurses' station. There was no one monitoring the telemetry.
An interview was conducted on 10-12-21 at 3:25PM with Staff #9, and #13. Staff #13 stated, "If we are all busy then there is no one to watch the monitors but they have alarms."

Staff #9 stated that there should be someone at the desk watching the monitors. Staff #9 confirmed there was no individual assigned to be responsible for monitoring the telemetry.

Based on document review and interview the facility failed to ensure that a properly executed informed consent was completed in 3 (Patient #32, #33, and #34) of 3 patient records reviewed.

This deficient practice had the likelihood to cause harm to all patients undergoing surgery or procedures. The patients were consenting to a procedure before the risks and benefits had been explained to them by the physician or provider.


Findings Include:


Patient #32

A review of Patient #32's medical record was conducted on 10/12/2021 after 10:00 AM with Staff #44 and revealed the following:

Patient #32 was scheduled for a "Bilateral Lumbar 4 Transforaminal Epidural Steroid Injection" by Staff #40 on 9/21/2021. The procedure consent was signed by Patient #32 on 9/22/2021 at 9:22 AM and witnessed by Staff #41. A review of the History and Physical dated 9/21/2021 at 8:16 AM did not reveal any documentation that the procedures risk and benefits had been discussed with the patient. Staff #40 signed the consent at 10:20 AM but the signature and time could not be validated because it was illegible.

Staff #44 provided the Operative note dated 9/21/2021 dictated by Staff #40. A review of the Operative note was as follows:

" ...Description of Procedure:

Patient Positioning:
-After informed consent and adequate discussion of the risks, benefits, and alternatives, the patient was taken to a Tulsa Spine and Specialty Hospital procedure room and placed on a radiolucent table in the prone position ..."

Staff #44 confirmed that no documentation of the risks and benefits of the procedure was documented by Staff #40 prior to the procedure. Staff #44 also confirmed that the facility where the procedure was completed was not Tulsa Spine and Specialty Hospital.

A review of the document titled "DISCLOSURE AND CONSENT; MEDICAL AND SURGICAL PROCEDURES; ANESTHESIA AND/OR PERIOPERATIVE PAIN MANAGEMENT (ANALGESIA)" revealed Patient #32 signed a consent for "Moderate Sedation" on 9/21/2021 at 9:22 AM. The consent was witnessed by Staff #41.


A review of the document titled, "Anesthesia Pre-procedure Plan" revealed the anesthetic plan and risks were discussed with the patient. Staff #43 completed the Anesthesia Pre-procedure evaluation on 9/21/2021 at 10:06 AM.


Staff #41 had Patient #32 sign the informed consent 44 minutes prior to the risks and benefits of anesthesia being discussed with the patient.



Patient #33

A review of Patient #33's medical record was conducted on 10/12/2021 after 10:00 AM with Staff #44 and revealed the following:

Patient #33 was scheduled for a "Bilateral Lumbar 5 Transforaminal Epidural Steroid Injection" by Staff #40 on 9/21/2021. The procedure consent was signed by Patient #33 on 9/21/2021 at 10:00 AM and witnessed by Staff #42. A review of the History and Physical dated 9/21/2021 at 8:29 AM did not reveal any documentation that the procedure risk and benefits had been discussed with the patient. Staff #40 signed the consent on 9/21/2021 at 10:41 AM but the signature, date, and time could not be validated because it was illegible.

Staff #44 confirmed no documentation of the risks and benefits of the procedure was documented by Staff #40 prior to the consent being signed by Patient #33.


A review of the document titled "DISCLOSURE AND CONSENT; MEDICAL AND SURGICAL PROCEDURES; ANESTHESIA AND/OR PERIOPERATIVE PAIN MANAGEMENT (ANALGESIA)" revealed Patient #33 signed a consent for "Moderate Sedation" on 9/21/2021 at 10:00 AM. The consent was witnessed by Staff #42.


A review of the document titled, "Anesthesia Pre-procedure Plan" revealed the anesthetic plan and risks were discussed with the patient. Staff #43 completed the Anesthesia Pre-procedure evaluation on 9/21/2021 at 11:06 AM.


Staff #42 had Patient #33 sign the informed consent 1 hour and 6 minutes prior to the risks and benefits of anesthesia being discussed with the patient.



Patient #34

A review of Patient #34's medical record was conducted on 10/12/2021 after 10:00 AM with Staff #44 and revealed the following:

Patient #34 was scheduled for a "Bilateral Lumbar 4 and 5 Transforaminal Epidural Steroid Injection" by Staff #40 on 9/21/2021.

A review of the document titled "DISCLOSURE AND CONSENT; MEDICAL AND SURGICAL PROCEDURES; ANESTHESIA AND/OR PERIOPERATIVE PAIN MANAGEMENT (ANALGESIA)" revealed Patient #34 signed a consent for "Moderate Sedation" on 9/21/2021 at 8:00 AM. The consent was witnessed by Staff #42.


A review of the document titled, "Anesthesia Pre-procedure Plan" revealed the anesthetic plan and risks were discussed with the patient. Staff #43 completed the Anesthesia Pre-procedure evaluation on 9/21/2021 at 9:19 AM.


Staff #42 had Patient #34 sign the informed consent 1 hour and 19 minutes prior to the risks and benefits of anesthesia being discussed with the patient.



An interview was conducted with Staff #6 on 10/12/2021 after 10:00 AM. Staff #6 was asked who had the patient sign the informed consent for a procedure or anesthesia. Staff #6 stated, "The Pre-op nurse completes the consents." Staff #6 was asked how the nurse knew if the Physician or Provider had discussed the risks and benefits of the procedure or the anesthesia with the patient.. Staff #6 said, "The Pre-op nurse should not have the informed consent signed until she knew if the risks and benefits had been discussed with the patient."

Staff #6 and Staff #44 confirmed the findings.


A review of the facility policy titled, "Informed Consent Policy-DIV-AM", Policy Number: 46950.2, and a Divisional Approval Date of 6/8/2021 was as follows:

" ...Purpose: To provide guidelines in the informed consent process.

Procedure:
1) It is the duty of the treating physician to obtain a patient's consent for treatment or procedure; this duty cannot be delegated nor is it eliminated, lessened, or spread by having the nurse secure the patients' signature before surgery or procedure.

2)Before a patient or person authorized to consent for a patient gives consent to any medical care or surgical procedure that appears on The Texas Medical Disclosure Panel's list requiring disclosure, the physician shall disclose to the patient or person authorized to consent for the patient:
a) the potential benefits, risks, and side effects of the patient's proposed care, treatment and services.
b) the likelihood of the patient achieving his or her goals.
c) any potential problems that might occur during recuperation.

3) The informed consent process also includes a discussion about reasonable alternatives to the patient's proposed care, treatment, and services. The discussion encompasses risks, benefits, and side effects related to the alternatives. Also included in the informed consent process is a discussion about any circumstances under which information about the patient must be disclosed or reported. The physician documents the above discussions when signing the informed consent ..."


Staff #6 and Staff #44 confirmed the findings.

Based on observations, review of records, and interview, the facility failed to ensure:

A) that the 2020-2021 Infection Prevention Evaluation, Plan, and Risk Assessment included an assessment of all areas of the hospital to identify potential sources and transmission of infection. The risk assessment failed to look at 8 areas [Plant Operations, Pharmacy Services, Laboratory Services, Radiology Services, Therapy Services (Physical Therapy, Occupational Therapy, Speech Therapy), Central Supply, Dietary Services, and Public Areas of the Hospital] out of 11 potential Care, Treatment, and Service areas;

B) that a water management team was formed and a comprehensive water management plan was developed per Division Policy in order to prevent waterborne sources and transmission of infections;

C) that a sanitary environment was maintained in 7 areas (Plant Operations, Dietary Services, Emergency Department, Therapy Services, Medical/Surgical/Intermediate Care Units, Radiology Services, and Surgical Services areas)

Findings for A) included:

On 10-14-2021 at approximately 11:20 AM, Staff #7 was interviewed regarding the Infection Prevention Evaluation, Plan, and Risk Assessment for 2020-2021. Review of Staff #7's employee file showed that Staff #7 had the necessary training to for the position of Infection Preventionist and had been in the position since 2019.

Upon review of the 2020-2021 Infection Prevention Evaluation, Plan, and Risk Assessment, it was noted that the only Care, Treatment, and Services evaluated under the Risk Assessment for the plan were Medical/Surgical/Intermediate Care Units, Emergency Department, and Surgical Services. Eight (8) Care, Treatment, and Services areas of the Hospital were not evaluated for potential risks of sources and transmission of infection. These areas included Plant Operations, Pharmacy Services, Laboratory Services, Radiology Services, Therapy Services (Physical Therapy, Occupational Therapy, Speech Therapy), Central Supply, Dietary Services, and Public Areas of the Hospital. During interview, Staff #7 confirmed that she had not included the other areas of the hospital in the Risk Analysis.

Findings for B) included:

On the morning of 10-12-2021 a tour of the Plant Operations Areas was made with Staff #4 and Staff #45. A water fountain and pool were observed in the front portion of the hospital lobby and another pool water feature was observed at the back of the lobby. The two water features had live plants around their edges.

Staff #4 and Staff #45 were interviewed on the testing, treatment, and care of the water features. Staff #4 explained that every Friday, a contracted company, Chem-Aqua, came in to check and fill the chemicals in the automatic chemical feeders for the water and tested the water at that time. Staff #4 stated that the water features were checked annually for Legionella. He stated the water features were drained once a year for cleaning.

A tour was then made of the Chiller Room and Boiler Room where water was chilled for the air conditioning system and hot water supplies for the hospital were heated. An automatic chemical dispensing system was observed in the boiler room.

Staff #4 was asked for the logs for testing for Legionella and weekly chemical testing results for the water features. Staff #4 stated that he did not keep a log of the weekly testing and neither did the company. The cooling towers were checked annually for Legionella and results provided. However, the water features were not checked for Legionella.

The Chem-Aqua contract was requested and provided by Staff #45.
Review of the contract was as follows:
Page 1: "The systems covered by this AGREEMENT: Cooling Tower(s) and Boiler(s) and Closed Loop System(s)."
Page 6: "This contract does not include Legionella risk assessments or Legionella risk management program. Chem-Aqua is providing the services described in this Agreement only, and no services relating to Legionella risk management beyond the normal and temporary mitigation of biological fouling."

After reviewing the contract, the water features were inspected again with Staff #45 on the afternoon of 10-12-2021. Staff #45 was shown vegetative matter that was floating in the water feature at the back of the lobby. Staff #45 was shown the sediment ring just above the water line on both pools. The surveyor ran a finger across the sediment line and Staff #45 was shown the heavy amount of black sediment that came off the side of the water feature from under the white ring.

The hospital's Water Management Plan was requested. Policy Title: 20-203 Water Management Plan-DIV-PE, Policy Number 40529.1, Effective Date 1/31/2021 was provided. Review of this policy showed that it was a Divisional policy that was applicable to multiple UT Health facilities, including UT Health Pittsburg. Review was as follows:

"Policy: According to the Centers for Disease Control and Prevention (CDC), 85 percent of all Legionnaires' disease outbreaks were attributed to water system exposures that could have been prevented by effective water management programs (WMP). Legionnaires' disease is a severe pneumonia caused by Legionella, a waterborne bacterium. Legionella species are gram-negative bacilli, measuring 2 to 20µm, found naturally in freshwater environments. Legionella is of concern when it grows and spreads in water systems. Those most susceptible to the disease are people age 50 or over; those with a history of smoking, chronic disease, immunosuppression, or cancer; or people with underlying illness such as diabetes, kidney failure, or liver failure. Besides Legionella species, there are many opportunistic waterborne pathogens, such as Pseudomonas, Acinetobacter, Burkholderia Stenotrophomonas, non-tuberculous mycobacteria, and fungi. Effective WMPs not only reduce the risk of Legionella growth, but also prevent growth of other waterborne pathogens.

Scope, Goals, and Objectives:
1) Establish a water management team to comply with ASHRAE standard 188 and CDC toolkit. Team shall consist of Facilities Management, Infection Preventionist, and other departments for whom water quality could impact patient care or safety.
2) Describe building water systems using text and flow diagrams.
3) Identify at-risk populations.
4) Identify areas, equipment, and systems at risk where Legionella could grow and spread.
5) Assign responsibility to implement risk mitigating strategies.
6) Establish actions to monitor the strategy parameters.
7) Decide where control measures should be applied and how to monitor them.
8) Establish interventions when control limits are not met.
9) Communicate throughout the facility.
10) Document all the activities.
11) Ensure the program is running as designed and is effective by reviewing the program periodically."

Staff #45 was interviewed about this policy. Staff #45 confirmed that this was a Divisional policy that outlined the requirements for a Water Management Plan. Staff #45 confirmed that a specific water plan for UT Health Pittsburg was not developed and/or available.

On 10-14-2021 at approximately 11:20 AM, Staff #7 was interviewed regarding the Infection Prevention Evaluation, Plan, and Risk Assessment for 2020-2021. During the interview, the Division policy for a Water Management Plan above was reviewed. Staff #7 stated that there was not a Water Management Team and that the requirements of the policy had not been completed for UT Health Pittsburg, nor were they addressed in the Infection Prevention Evaluation, Plan, and Risk Assessment for 2020-2021.


Findings for C) included:

PLANT OPERATIONS AREAS

On the morning of 10-12-2021 a tour of the Plant Operations Areas was made with Staff #4 and Staff #45. A tour of the Chiller Room and Boiler Room were made. These areas were cluttered with excess materials being stored. The manner in which items were being stored made it difficult to get to plant equipment in these rooms and difficult to keep the floors clean. The clutter, dirt and trash on the floors created an environment and potential habitat for insects and rodents, as well as bacterial and fungal growth.

Observations included:

Cardboard boxes were stored on the concrete floors, behind work cabinets, in corners and around water tanks. Evidence of dried liquid spills were on the floors and cardboard boxes had evidence of being damp, drying, and degrading. This could provide a place for insects to lay eggs, rodents to nest, and wet cardboard can grow bacteria and fungus such as mold and mildew.

Dead insects were observed on the floor around these boxes, in corners, in open containers such as empty buckets, open laundry soap bucket, and on top of the cardboard boxes.

Scraps of paper trash were observed on the floors.

A serviceable hospital bed was stored near the chiller plumbing with miscellaneous items stacked on top of the mattress. There were dead insects observed on the floor near the bed. Storage in this manner creates the potential to compromise the mattress covering, allowing insects and rodents to enter into the mattress. This could potentially carry dirt, insects, and rodents to other parts of the hospital.

Multiple dirty linens, towels, and rags were observed scatter around the two rooms. These items have the potential to provide nesting material for rodents and a place for insects to nest and lay eggs.

Scrap wood and a piece of scrap dry-wall material was scattered around a 500-gallon potable water tank. This had the potential to create a habitat for wood rats and other rodents as well as hide insects.

A clothes washing machine was observed in the boiler room. The washing machine was the type found in private homes. When the lid was opened, a load of laundry was observed. The laundry had been washed and had sat in the machine so long that it was stiff, dry, and stuck to the walls of the wash tub after going through a spin cycle. The washing machine had a buildup of dirt on the outside and under the lid of the machine. This had the potential for bacterial and fungal growth.

The air-handler cabinets for the commercial air conditioning system were on the roof. Wooden steps were used to access each of the four entrances into the cabinets. All four sets of steps were observed to have rotted wood. This had the potential to provide an environment for termite infestation or other wood boring insects that could then gain access to the hospital.

The medical gas room was observed to have trash, debris, equipment, and dead insects on the floor of the room and under the portable oxygen cylinder storage rack.

DIETARY SERVICES AREA

At approximately 11:00 AM, a tour of the Dietary Services Areas was made with Staff #45, Staff #24, and Staff #25.

A food storage rack was observed to have 8 canned food items and 2 plastic food container items on them that did not have the item received date. Staff #24 confirmed that items were supposed to be marked with date received so that food items would be used in the "First In-First Out" method. This method ensured that food items don't go bad from sitting too long at the back of a shelf and then get served to patients.

A large storage bin of white rice was observed to have passed the use-by date on the container.

Plastic individual-portion cups were observed to stored in an open cardboard box on a shelf. Cups had been removed from the plastic sleeve and were stored in a manner that would allow contaminants, if present, to fall into the cups.

A metal ice scoop was observed in blue plastic container on the wall next to the ice machine. The outside and inside of the plastic container was observed to be dirty. Black sediment in clear liquid was observed at the bottom of the container where the ice scoop was resting. This created an environment for possible transmission of waterborne illness.

A container of Pimento Cheese was observed in the walk-in refrigerator. The container had been opened and the lid had not been put on to completely seal the container. The container had not been dated as to when it had been opened and had the potential to be expired.

Six containers of frozen fortified shakes were observed in the small freezer for patient food items. All six shakes had an expired use by dates of June 30, 2021.

A large, 11-serving-can of condensed soup was observed in the can storage rack. The can had dents along the edges of the top and bottom lids of the can, along the seam. Large dents along lid seams had the potential to allow the contents to spoil.

A small double-door refrigerator was observed to have door seals that were dirty with appeared to be mildew, sticky food matter, food particles in the folds of the seals and both door seals were torn.

Review of policy Title: Sanitation Standards for Food Services-DS, Policy Number 69159.1, Effective Date: 09/16/2020 was as follows:

"Food Supplies
1) General
a) Food shall be in sound condition, free from spoilage, filth or other contamination and shall be safe for human consumption.
...
3) Food Protection:
a) General: At all times including while being stored, prepared, displayed, served, or transported, food shall be protected from potential contamination, including dust, insects, rodents, unclean equipment and overhead leakage or overhead drippage from condensation. The internal temperature of potentially hazardous food shall be 45 degrees F or below or 140 degrees F or above at all times, except as otherwise provided in these rules.
4) Food Storage:
a) General:
i) Food whether raw or prepared, if removed from the container or package in which it was obtained, shall be stored in a clean covered container except during necessary periods of preparation or service. Containers shall be impervious and non-absorbent, except that linens and napkins may be used for lining or covering bread or roll containers. Solid cuts of meat shall be covered in storage.
ii) Containers of food shall be stored a minimum of 6 inches above the floor in a manner that protects the food from splash and other contamination and that permits easy cleaning of the storage area.
iii) Food and containers of food shall not be stored unde4e4er exposed unprotected sewer lines or water lines, except for fire protection heads that may be required by law. The storage of food in toile rooms or vestibules is prohibited.
iv) Food not subject to further washing or cooking before serving shall be stored in such a way that protects it against cross-contamination from food requiring washing or cooking.
v) Packaged food shall not be stored in contact with water or undrained ice. Wrapped sandwiches shall not be stored in direct contact with ice.
vi) Unless the identity is unmistakable, bulk food such as cooking oil, syrup, salt, sugar, or flour not stored in the product container or package in which it was obtained shall be stored in a container identifying the food by common name. Dispensing utensils such as scoops shall not be stored in bulk food containers, and shall be cleaned after each use.
vii) All food products shall be dated and the time they are received if date not already in place on product.
(1) Boxes or individual containers shall all be labeled (with date) so the date remains visible when unpacked from the case.
(2) New containers of product are always placed behind the previously received packages of the same products. In other words, rotate stock the FIFO method. (First In First Out)
(3) Any shelved package which is opened and of the contents not used at once, will have the remaining products transferred to an airtight container labeled with the date it was opened.
(4) Frozen food products also will be dated when received and again after opening and transferring to another container. All dates will contain month, day, year."



32143


EMERGENCY DEPARTMENT AREA

A tour was conducted on 10-11-21 at 3:22PM with Staff #10 and #5.
Storage Room outside of the Emergency Department:
The room was to store cleaning supplies and clean equipment. There was trash overflow and trash lying on cleaning supplies.
Cleaning equipment was found sitting on a dirty floor.
The wet mop had an orange, greasy, dirty substance caked on top.
The floor was heavily soiled with dirt, dust, and dead bugs.
Cardboard boxes were found stored on the floor.
Staff #5 and #10 confirmed the findings.

A tour was conducted on 10-11-21 at 3:41PM with Staff #10 and #5 of the Emergency Department (ED).

ED CLEAN UTILITY ROOM
The patient clean linen was stored in the employee break room and patient food preparation area. The linen was also found uncovered.
The staff refrigerator and an ICEE machine was in the same room as the patient linen and snacks. The patient and employee food items, laundry and belongings from employee homes were all in the same room. There was no way to ensure the linen and patient food products were not contaminated.
Staff #5 and #10 confirmed the findings.

A tour was conducted on 10-12-21 at 10:30 AM with Staff #10 and #5 of the Emergency Department (ED).

TRIAGE ROOM
The work computer on wheels (WOW) and keyboard was heavily soiled with dirt, hair, and dust.
An emergency bag with equipment was found lying under the triage desk. The bag was found lying in dust and dirt on the floor. The bag was noticeably soiled.
The floor in the triage room was soiled with dust, dirt, pens, and candy.
The blood pressure cart on wheels was soiled with dust, dirt, and hair.
The nurse's desk was soiled with dust, and hair. A foley catheter, cotton tipped applicators and tongue depressors were found on the desk under papers and laminated cards.
The patient stretcher was soiled with dirt, dust, hair, old tape, and the end of an IV cap.

EMERGENCY AREA
The two WOW's out in the hallway for use was soiled with dust, dirt, and hair.
The infant scale was found to have papers and equipment sitting on top of it. The scale was soiled with dirt and dust. It was not available for immediate use. After all the paraphernalia was removed from the top of the infant scale a sign was found. The sign stated, "Please leave on IV cart. Put scale on solid surface for accurate reading." The scale was on the back of the nurse's station on a desk.
Working thermometers that were used on patients were found thrown in a soiled junk drawer in the nurse's station. The drawer had cords, booklets, metal objects, pens, and a rope.
Inside the Pyxis (medication cabinet) was a box of conscious sedation medications, tweezers, and pliers. The container was soiled with a rusty dried substance, dust, and dirt. The inside bottom of the Pyxis was soiled with dirt, dust, and hair.

SOILED ROOM
In the soiled room back boards and a ladder were found mixed in with the dirty laundry and trash.
Cleaned bedside commodes were found uncovered sitting next to soiled trash and the flushing hopper. The chairs were found rusted.
Next to the bedside commode chairs and the soiled red bag container was a heavily soiled 4 prong walker and two wooden canes.
In the soiled room the staff were storing lost and found items in a box on the floor.
Staff #10 confirmed the walker and canes were patient items and needed to be discarded. Staff #10 confirmed the patient lost and found were being held in the soiled linen room. If the patients were to receive back their items they would have been possibly contaminated. Staff #10 confirmed the cleaned bedside commodes were in the soiled room. Staff #10 stated he was told by another surveyor during a different survey, that the commodes should be held in the soiled room even if they were cleaned. Staff #10 agreed if the soiled items were cleaned per protocol it should be in a clean room since it would be going to another patient.

THERAPY SERVICES AREA

A tour was conducted on 10-13-21 at 9:33 AM with Staff #10 of the Physical Therapy Room and Medical Floor.

PHYSICAL THERAPY ROOM
Two portable exercise foot pedals were found stored under the desk. One of the pedals metal base had plastic cap tips on the end to protect the floor. One of the caps was covered in tape. The tape was covered in dirt and hair.
Crutches, canes, and a walker were found sitting on the wooden base of the parallel bars. The wooden base was covered in hair and dirt.

MEDICAL/SURGICAL/INTERMEDIATE CARE UNITS

MEDICAL FLOOR
In the patient nutrition room, the food refrigerator was sitting on the floor. The bottom of the refrigerator was soiled with dirt, dust, and hair.
The Pyxis on the medical side was found to be dirty with dust, dirt, and hair.
A medication refrigerator was found with medications inside and a top freezer section. The freezer part was iced over and unable to be cleaned.

EQUIPMENT ROOM
The equipment room was also the clean patient supply room mixed in. A cart was found soiled with dust, dirt, and rust.
Three metal stools were found soiled and rusted.
A cast saw was found sitting on the floor with a urinal sitting on top of it. The cast saw was soiled with dust.
Patient cast and bandage supplies were mixed in with emergency radios, batteries, and office supply.
The stockinette used for casting an extremity was found unwrapped from the original box and hanging down on top of walkie talkie radios.

SPECIAL BATHING ROOM
A room was found for bathing a patient. The room had a toilet in it and a full open shower. The room was full of equipment. A shower chair was found soiled with mold.
A wheelchair was found in the shower room stored. The wheelchair was broken and had the arm taped up with silk medical tape. The chair was soiled with dust and dirt.
A bariatric vinyl chair was found stored in the shower room. The chair was ripped on the back piece.
A mat and two fold up beds were found in the shower room. The mat was found sitting on the soiled floor.
Cleaned bed side commodes were found stored in the soiled room with dirty laundry and trash.
In the second equipment cleaned IV poles and an IV pump were found. A pole was found with a rusted bottom.

PATIENT ROOM 104
The lounge chair was torn on the footrest and on the seat.


40989

RADIOLOGY SERVICES

RADIOLOGY/ULTRASOUND ROOM

During an observation tour on 10/13/2021 at 3:15 PM with Staff #16 and Staff #32 the following was observed:

The mattress on the bed used for Ultrasound procedures was noted torn in multiple places. On both sides and at the head of the mattress. Once the bed was flexed a metal frame was exposed. The metal frame was noted to be rusted, dirty, missing paint, and exposing the metal surface. The mattress that covered the metal frame was noted to be torn and have a red colored stain. Staff #16 and Staff #32 could not confirm or deny if it was old blood. Underneath the bed, on the metal frame, there was a hole on both sides of the frame. The holes had a rough edge resembling corrosion. Below the holes was a dried liquid that could not be confirmed or denied as blood.

Staff #16 and #32 confirmed the findings.


SURGICAL SERVICES

SURGERY DEPARTMENT

An observation tour was conducted on 10/12/2021 at 9:10 AM with Staff #6. The following was observed.


A review of the document titled, "Room Temperature & Humidity Log" for the months of August, September, and October 2021 was as follows:


" ...The OR rooms and Sterile Processing Department will be maintained in accordance with the American Institute of Architects (AIA). AIA/Association of Operative Registered Nurses (AORN) recommends that the IR temperature be maintained between 68-75 degrees F and the relative humidity maintained between 20% and 60% (Please see policy and procedure for temperatures lower or higher than recommended range).
The sterile processing department (prep and pack) temperature would have a temperature controlled between 72-78 degrees F.
The decontamination area should have a temperature controlled between 72-78 degrees F.
The temperature in the Sterile storage areas (staging) may be as high as 78 degrees F.
The relative humidity in all Sterile Processing Department and storage areas should be controlled between 20% and 60%.
If the humidity is out of range, please notify Plant Services.
If in a procedure room, notify the physician and continuation of the procedure will be at their discretion and documented. If surgeon decides to proceed with humidity out of range, Infection Control is to be notified ..."

OR Room 1
August:
There was no documentation of the temperature or humidity for 10 of 31 days reviewed. There were 9 days that the humidity was out of range and no documentation that Plant Services was notified or corrective action was taken.

September:
There was no documentation of the temperature or humidity for 9 of 30 days reviewed. There were 14 days the humidity was out of range and 3 days temperature was out of range. No documentation that Plant Services was notified. Only one day was documented for corrective action but no documentation of recheck of the temperature or humidity was completed.

October:
There was no documentation of the temperature or humidity for 4 of 12 days reviewed. There were 6 days the humidity was out of range and only 1 day documented that Plant Services was notified. No documentation of corrective action or recheck of the humidity was completed.


OR Room 2
August:
There was no documentation of the temperature or humidity for 10 of 31 days reviewed. There was 13 days that the humidity was out of range and no documentation that Plant Services was notified or corrective action was taken.

September:
There was no documentation of the temperature or humidity for 9 of 30 days reviewed. There was 14 days the humidity was out of range and 3 days the temperature was out of range. There was no documentation that Plant Services was notified. Only one day was documented for corrective action but no documentation of recheck of the temperature or humidity was completed.

October:
There was no documentation of the temperature or humidity for 4 of 12 days reviewed. There was 5 days the humidity was out of range. There was no documentation the Plant Services was notified, or corrective action taken.


During the observation tour on 10/13/2021 at 3:15 PM it was noted that an Anteroom (a room between OR 1 and OR 2) was not monitored for temperature or humidity. Inside this room was sterile supplies such as a multi-tier metal cart that held sutures, multiple peel packed instruments, and an autoclave (used to sterilize instruments).

Staff #6 confirmed that this room was not monitored for temperature and humidity ranges.


GI Lab Procedure Room
August:
There was no documentation of the temperature or humidity for 10 of 31 days reviewed. There were 7 days the temperature was out of range. There was no documentation that Plant Services was notified. Only one day was documented for corrective action. Documentation on 8/31/2021 revealed thermometer broken /reordered on this day.

September:
There was no documentation of the temperature or humidity for 23 of 30 days reviewed. There was 1 day the humidity was out of range. There was no documentation that Plant Services was notified. No documentation of recheck or corrective action for the humidity was completed.

October:
There was no documentation of the temperature or humidity for 4 of 12 days reviewed.


Sterile Supply
August:
There was no documentation of the temperature or humidity for 10 of 31 days reviewed.

September:
There was no documentation of the temperature or humidity for 10 of 30 days reviewed

October:
There was no documentation of the temperature or humidity for 4 of 12 days reviewed.


Sterile Processing
August:
There was no documentation of the temperature or humidity for 11 of 31 days reviewed.

September:
There was no documentation of the temperature or humidity for 10 of 30 days reviewed

October:
There was no documentation of the temperature or humidity for 4 of 12 days reviewed.


An interview was conducted with Staff #6 on 10/13/2021 after 10:00 AM. Staff #6 was asked what National Guidelines they follow to monitor their temperature and humidity in Surgery Department. Staff # 6 stated, "AORN." Staff #6 was asked about the GI Lab room for the month of September and why was it not monitored. Staff #6 stated, "We had to order a new thermometer for that room. I just call Plant Services and tell them we need one and we did that at the end of August when it quit working." Staff #6 was asked why the Department was using two different forms. Staff #6 confirmed he did not know. Staff #6 was then asked why the Ante Room in between OR 1 and OR 2 was not being monitored for temperature and humidity when there were sterile supplies stored in the room. Staff #6 stated, "I guess we just didn't think about that."


During an interview with Staff #4 on 10/14/2021 after 11:00 am it was confirmed that a new Hygrometer was ordered on 9/27/2021. Staff #4 confirmed this was the day he was made aware that a new one was needed. A review of the Purchase order revealed a new one was ordered on 9/27/2021 and received on 9/29/2021.


A review of the facility policy title, "2000 Humidity-Temperature Control-SS", Policy Number: 57770.1 with an effective date 8/22/2019 was as follows:

" ...Policy: Provide guidelines for the environmental control systems in the surgery department.

Objectives:
These rooms will be designed and maintained in accordance with the Guidelines for the Design and Construction of Health Care Facilities. It is recommended that the:
1) OR and procedure rooms temperatures are maintained between 68 degrees F and 73 degrees F and the relative humidity maintained between 20% and 60%.
2) Sterilization Room Temperature is maintained between 68 degrees F and 73 degrees F and the relative humidity maintained between 30% and 60%.
3) Sterile Storage and Supply Room temperature greater than 75 degrees F and relative humidity maintained between 20% and 60%.

Procedure:
1) Relative humidity/temperature levels will be monitored and recorded daily. Relative humidity will typically be maintained in accordance with recommended ranges. Discrepancies in temperature or humidity will be corrected if possible and documented on the relative humidity/temperature log in each area being monitored ...
2) ...
3)The temperature/humidity log books are kept in each room, showing daily documentation. When the recommended limits are violated and the log should note that the surgeon was made aware of the low/high humidity/temperature level if efforts to correct the violation have not been met.
4) Infection Control Department should be notified, and a log of activity in the area should be forwarded to them for follow-up ..."


Staff #6 confirmed the staff in the OR were not following the policy and documenting corrective actions and a recheck on the temperature and humidity. No documentation of the Infection Control Department being notified was completed.



A review of the 2019 AORN Guidelines was as follows:

Guidelines for Perioperative Standards and Recommended Practices. Association of perioperative Registered Nurses-2019 Perioperative Standards and Recommended Practices, e-AORN, Table 3.

"Temperature should be maintained between 68 degrees F to 75 degrees Fahrenheit (20 degrees to 24 Celsius) within the operating room suite. General work areas in sterile processing clean workroom should be maintained between 68 degrees to 73 degrees Fahrenheit (20-23 Celsius). Sterile storage room should be maintained below 75 degrees Fahrenheit (24 degrees Celsius). Sterile processing decontamination area should be maintained between 60 degrees to 73 degrees (16-23 Celsius).

Relative humidity should be maintained between 20% and 60% within the perioperative suite, including operating rooms, recovery area, cardiac catheterization rooms, endoscopy rooms, and should be maintained below 60% in sterile processing clean work room and sterile storage areas.


Staff #6 and Staff #33 confirmed the above findings.