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Based on observation, interview and record review the facility failed to ensure identified sanitary environment deficient practices in the laboratory were corrected in 1 of 1 laboratory department. They failed to ensure the Infection Control Officer reported and documented identification of infection control problems in the lab department. They failed to ensure their quality assurance program had documentation of performance improvement activities being tracked and sustained in the lab department.
This deficient practice had the likelihood to cause harm in all patients.
Findings include:

*During an observation on 08/19/2014 after 11:00 a.m. the baseboards behind lab equipment in the microbiology area had a buildup of dust and dirt.
During an interview on 08/19/2014 after 11:00 a.m., Staff #5 confirmed the observations.
Review of a CMS 2567 dated 06/26/2014 revealed a plan of correction with a completion date of 07/08/2014 revealed during observation on 06/26/2014 the floor in the microbiology area of the laboratory had an original color which was mingled with light blue and white. The middle of the floor had turned black and the base boards had a build-up of dust and dirt. The baseboards behind equipment in the area had a buildup of dirt, dust, and paper.
The facility documented on the CMS 2567 that on 06/26/2014, a deep cleaning process was initiated on the floors in the Microbiology lab and progressed throughout the entire laboratory area. The Laboratory Director and the Director of Environmental Services developed and implemented a schedule for daily, weekly cleaning and a deep cleaning at the end of each month. The completion date was for 07/08/2014 and this was not followed.

* During an observation on 08/19/2014 after 11:00 a.m., six bottles of sterile water was found on a shelf in front of a glass window (exposed to sunlight). The instructions on the label revealed they were to discard unused portion. Recommendations for storage were for the room temperature (25 degrees Celsius). Avoid excessive heat.
A bottle of sterile water (irrigation) which was mixed with Mucolyse (a sputum liquefying agent used to digest and thin out the sputum, thus enhancing the isolation of organisms responsible for chronic lung disease) was found stored in the refrigerator.
Review of facility provided information on "Sterile Water for Irrigation, USP" dated 06/26/2014 revealed "Sterile Water for Irrigation, USP (United States Pharmacopeia) contains no bacteriostatic, antimicrobial agent or added buffer and is intended for use only as a single-dose or short procedure irrigation. When smaller volumes are required the unused portion should be discarded."
Staff #4 and #5 and confirmed the observations.
Review of a CMS 2567 dated 06/26/2014 revealed a plan of correction with a completion date of 08/15/2014 revealed bottles of sterile water used for irrigation was found on another shelf in the room in front of a glass window (exposed to sunlight). Staff were opening the single use bottles of sterile water and reusing them.
Review of the plan of correction on the CMS 2567 revealed the utilization of sterile water in the laboratory was reviewed. It was determined that single use vials would be used throughout the laboratory when sterile water was indicated ...
The appropriate care and storage of specimens within the laboratory was reviewed by the Laboratory Director and Managers. Laboratory staff was in-serviced on the revised Respiratory Culture Policy and were observed performing core competencies for their specific area of the laboratory.
The Infection Control Practitioner had retrospectively reviewed outcomes for patients that initially tested positive for Pseudomonas on post procedural bronchial washings. The DNA test results from the State Laboratory had confirmed that the Pseudomonas correlated to the non-sterile additive used when the cultures were being processed.
The plan of correction had the correction dates of 06/24/2014, 07/3102104 and 08/15/2014 for these deficient practices and the facility failed to ensure it was followed.

*During an interview on 08/19/2014 at 11:55 a.m., Staff #3 reported she was making environmental rounds on her own in the laboratory. Some of the concerns she found was problems with the staff eating area, the window blinds and one staff handling specimens without gloves on. There was a concern and discussion on if the lab staff training was appropriate. Staff #3 reported she had not made rounds with the Environmental Operations Committee. The last round the EOC made was in July 2014 and that did not include the lab. The lab rounds were not due until November.
Review of a "Surveillance Plan 2014" revealed Staff #3 documented rounds were performed in the lab on 07/08/2014 and there were no findings. Rounds were made on 07/10, 07/14, 07/17, 07/22, 07/24 and 07/27/2014. There was no documentation of findings on each visit to the lab. Underneath the section for "Recommendations" there was documentation that staff was reminded to keep cardboard boxes out of the lab. There was no indication as to when this was found or follow-up documentation. There was also no documentation of Staff #3's identified concerns.
Review of the CMS 2567 dated 06/26/2014 revealed documentation in the plan of correction that the Infection Control Practitioner would facilitate the quality assurance and improvement efforts related to infection control through ongoing surveillance and participation in the EOC rounds. The completion date for this plan was 07/31/2014 and it was not done.

*Review of a quality council meeting minutes dated 07/15/2014 revealed the lab reporting was deferred. Underneath the follow-up section was documentation that revisions were being made to the policy and process for critical lab. The following documentation was found on the form:
"A review was provided of the current follow-up in process related to recent State, CMS, and Joint Commission Surveys. All action plans are in plan and deadlines for submission have been met. Data is being reported as outline within the action plans." There was no documentation of what plans that were implemented or actions taken as a result of the survey visit from 06/06/2014.
During an interview on 08/19/2014 after 11:45 a.m., Staff #2 reported they had implemented specific performance improvement plans for the lab director to be following. Staff #2 confirmed the information was not included in her quality minutes dated 07/15/2014, but they should have been included.

Based on observation, interview and record review the facility failed to ensure identified sanitary environment deficient practices in the laboratory were corrected in 1 of 1 laboratory department. They failed to ensure floors were cleaned and they failed to ensure ensure sterile water used for testing was used and stored properly.
They failed to ensure the Infection Control Officer reported and documented identification of infection control problems in the lab department.
This deficient practice had the likelihood to cause harm in all patients.
Findings include:

*During an observation on 08/19/2014 after 11:00 a.m. the baseboards behind lab equipment in the microbiology area had a buildup of dust and dirt.
During an interview on 08/19/2014 after 11:00 a.m., Staff #5 confirmed the observations.
Review of a CMS 2567 dated 06/26/2014 revealed a plan of correction with a completion date of 07/08/2014 revealed during observation on 06/26/2014 the floor in the microbiology area of the laboratory had an original color which was mingled with light blue and white. The middle of the floor had turned black and the base boards had a build-up of dust and dirt. The baseboards behind equipment in the area had a buildup of dirt, dust, and paper.
The facility documented on the CMS 2567 that on 06/26/2014, a deep cleaning process was initiated on the floors in the Microbiology lab and progressed throughout the entire laboratory area. The Laboratory Director and the Director of Environmental Services developed and implemented a schedule for daily, weekly cleaning and a deep cleaning at the end of each month. The completion date was for 07/08/2014 and this was not followed.

* During an observation on 08/19/2014 after 11:00 a.m., six bottles of sterile water was found on a shelf in front of a glass window (exposed to sunlight). The instructions on the label revealed they were to discard unused portion. Recommendations for storage were for the room temperature (25 degrees Celsius). Avoid excessive heat.
A bottle of sterile water (irrigation) which was mixed with Mucolyse (a sputum liquefying agent used to digest and thin out the sputum, thus enhancing the isolation of organisms responsible for chronic lung disease) was found stored in the refrigerator.
Review of facility provided information on "Sterile Water for Irrigation, USP" dated 06/26/2014 revealed "Sterile Water for Irrigation, USP (United States Pharmacopeia) contains no bacteriostatic, antimicrobial agent or added buffer and is intended for use only as a single-dose or short procedure irrigation. When smaller volumes are required the unused portion should be discarded."
Staff #4 and #5 and confirmed the observations.
Review of a CMS 2567 dated 06/26/2014 revealed a plan of correction with a completion date of 08/15/2014 revealed bottles of sterile water used for irrigation was found on another shelf in the room in front of a glass window (exposed to sunlight). Staff were opening the single use bottles of sterile water and reusing them.
Review of the plan of correction on the CMS 2567 revealed the utilization of sterile water in the laboratory was reviewed. It was determined that single use vials would be used throughout the laboratory when sterile water was indicated ...
The appropriate care and storage of specimens within the laboratory was reviewed by the Laboratory Director and Managers. Laboratory staff was in-serviced on the revised Respiratory Culture Policy and were observed performing core competencies for their specific area of the laboratory.
The Infection Control Practitioner had retrospectively reviewed outcomes for patients that initially tested positive for Pseudomonas on post procedural bronchial washings. The DNA test results from the State Laboratory had confirmed that the Pseudomonas correlated to the non-sterile additive used when the cultures were being processed.
The plan of correction had the correction dates of 06/24/2014, 07/3102104 and 08/15/2014 for these deficient practices and the facility failed to ensure it was followed.

*During an interview on 08/19/2014 at 11:55 a.m., Staff #3 reported she was making environmental rounds on her own in the laboratory. Some of the concerns she found was problems with the staff eating area, the window blinds and one staff handling specimens without gloves on. There was a concern and discussion on if the lab staff training was appropriate. Staff #3 reported she had not made rounds with the Environmental Operations Committee. The last round the EOC made was in July 2014 and that did not include the lab. The lab rounds were not due until November.
Review of a "Surveillance Plan 2014" revealed Staff #3 documented rounds were performed in the lab on 07/08/2014 and there were no findings. Rounds were made on 07/10, 07/14, 07/17, 07/22, 07/24 and 07/27/2014. There was no documentation of findings on each visit to the lab. Underneath the section for "Recommendations" there was documentation that staff was reminded to keep cardboard boxes out of the lab. There was no indication as to when this was found or follow-up documentation. There was also no documentation of Staff #3's identified concerns.
Review of the CMS 2567 dated 06/26/2014 revealed documentation in the plan of correction that the Infection Control Practitioner would facilitate the quality assurance and improvement efforts related to infection control through ongoing surveillance and participation in the EOC rounds. The completion date for this plan was 07/31/2014 and it was not done.