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Based on observation, testing, document review, record review, policy review, and interview, the provider failed to ensure the governing body was accountable for all in-patient and out patient services at the main facility and seven of seven off campus services (Spearfish Regional Medical Clinic, Regional Rehabilitation, Regional Surgery Center, Queen City Regional Medical Clinic, Regional Orthopedics, Regional Dermatology, and Regional Rehabilitation [Belle Fourche). To include:
*The review of all contracted services to include the effectiveness and the quality of service.
-Provider had no list or records of outside contracted services.
*Personal privacy for two of two observed patients (28 and 29) and one of one unobserved unidentified patient who received outpatient intravenous (IV) infusion therapy.
*An on-going quality assurance performance improvement (QAPI) program throughout the entire facility and seven of seven off campus services (Spearfish Regional Medical Clinic, Regional Rehabilitation, Regional Surgery Center, Queen City Regional Medical Clinic, Regional Orthopedics, Regional Dermatology, and Regional Rehabilitation [Belle Fourche).
*Dating and initialing multi-dose vials when opened in two of two patient care areas (dermatology clinic and orthopedic clinic).
*Single-use medication vials not used for more than one patient in one of one clinic (dermatology).
*Cleanable, durable surfaces and/or cleanliness was maintained in ten of ten areas:
-Obstetrics.
-Dermatology clinic.
-Operating room (OR) one at the surgery center.
-OR two at the surgery center.
-Suture supply shelves at the surgery center.
-Surgical case container storage shelves at the surgery center.
-OR 3 at the hospital.
-Equipment storage room of the OR suite at the hospital.
-The housekeeping closet in the medical/surgery (med/surg) area.
-The supply closet at the north end of the med/surg area across from patient room 118.
*Storage of cleaners and/or chemicals separately from patient use items in four of four areas:
-Hospital's main housekeeping supply room.
-Emergency room's [ER] dirty utility room.
-Dermatology clinic.
-Orthopedic clinic.
*Infection control practices, standards, and guidelines were implemented and maintained throughout the facility and three of three off campus services (Regional Surgery Center, Regional Orthopedics, and Regional Dermatology).
*Proper training and guidelines for high-level disinfection at wound care services in the main facility and sterilization of equipment at the dermatology clinic.
Findings include:

1. Based on record review and interview, the provider failed to create and maintain a quality of service program for any outside contracted services throughout the facility and off campus services (Spearfish Regional Medical Clinic, Regional Rehabilitation, Regional Surgery Center, Queen City Regional Medical Clinic, Regional Orthopedics, Regional Dermatology, and Regional Rehabilitation [Belle Fourche).
Refer to A084.

2. Based on observation, interview, and patient's admission packet review, the provider failed to ensure personal privacy was maintained for two of two observed patients (28 and 29) and one of one unobserved unidentified patient who received outpatient intravenous (IV) infusion therapy.
Refer to A143.

3. Based on record review, interview, and policy review, the provider failed to ensure a complete documented quality assurance performance improvement (QAPI) program was re-implemented and improved upon for 2015 and carried through for 2016 throughout the facility and for seven of seven off campus services (Spearfish Regional Medical Clinic, Regional Rehabilitation, Regional Surgery Center, Queen City Regional Medical Clinic, Regional Orthopedics, Regional Dermatology, and Regional Rehabilitation [Belle Fourche).
Refer to A263.

4. Based on observation, label review, and interview, the provider failed to ensure:
*Staff had put an opened date and their initials on multi-dose vials when opened in two of two patient care areas (dermatology clinic and orthopedic clinic).
*Single-use medication vials were not used for more than one patient in one of one clinic (dermatology).
Refer to A505.

5. A. Based on observation, testing, and interview, the provider failed to ensure cleanable, durable surfaces and/or cleanliness was maintained in ten of ten areas:
*Obstetrics.
*Dermatology clinic.
*Operating room (OR) one at the surgery center.
*OR two at the surgery center.
*Suture supply shelves at the surgery center.
*Surgical case container storage shelves at the surgery center.
*OR 3 at the hospital.
*Equipment storage room of the OR suite at the hospital.
*The housekeeping closet in the medical/surgery (med/surg) area.
*The supply closet at the north end of the med/surg area across from patient room 118.
Refer to A701 A.

5. B. Based on observation and interview, the provider failed to store cleaners and/or chemicals separately from patient use items in four of four areas (main housekeeping supply room, emergency room (ER) dirty utility room, dermatology clinic, and the orthopedic clinic).
Refer to A701 B.

6. Based on observation, label review, testing, interview, document review, and policy review, the provider failed to ensure the following:
*Obstetrics department: hinged instruments (scissors and forceps) were sterilized in the opened position.
*The six post-operative care bays: sharps and waste containers were installed.
*X-ray area: the one gurney pad did not have spider web cracks and threadbare surfaces.
*Throughout the facility:
-Disinfectants used throughout the facility were used according to manufacturers' directions.
-Patient care items (baby diapers and adult briefs) were protected from possible contamination.
-All ice machines and water dispensers were descaled and cleaned to prevent possible contamination.
*Operating room equipment: seven pieces (two IV poles, two cautery carts, one Medtronic Collator, one electrocautery machine, and one Sonosite Ultrasound) were maintained in a cleanable condition.
*Post acute care unit (PACU): two handwashing sinks provided a sufficient amount of water for proper hand hygiene.
*Central sterilization (CS): one clean linen cart on the clean side of central sterilization was cleanable and could be disinfected.
*Medical/Surgical unit: one whirlpool tub was kept clean and patient care items in that tub room were kept clean, protected, and organized.
*Seven of seven bulk laundry bins containing soiled linen were stored in a soiled linen or trash room.
*Personal protective coverings and eyewear were used when collecting soiled linen and trash throughout the facility.
*Proper instruction and guidelines were given to all cardiac rehabilitation patients who used all the CardioRehab machines.
Refer to A747.

7. Based on observation, interview, policy review, and manufacturer's recommendation review, the provider failed to ensure:
*The dermatology clinic's medical instrument sterilization procedure room was operated and constructed appropriately and according to sterilization guidelines.
*A handwashing sink was available in the sterilization room at the dermatology clinic.
*Cidex OPA was used appropriately, according to manufacture's directions, and according to sterilization guidelines in the wound care/foot clinic patient area of the main facility.
Refer to A940.

The cumulative effect of the above systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment at the main facility and seven off campus services:
*Spearfish Regional Medical Clinic.
*Regional Rehabilitation.
*Regional Surgery Center.
*Queen City Regional Medical Clinic.
*Regional Orthopedics.
*Regional Dermatology.
*Regional Rehabilitation (Belle Fourche).

Based on interview, the provider failed to create and maintain a quality of service program for any outside contracted service throughout the main facility and seven of seven off-campus services (Spearfish Regional Medical Clinic, Regional Rehabilitation, Regional Surgery Center, Queen City Regional Medical Clinic, Regional Orthopedics, Regional Dermatology, and Regional Rehabilitation [Belle Fourche).
Findings include:

1. Review of all governing board and advisory committee meeting minutes for 2015 through October 2016 revealed no indication or notation that any contracted service for the facility and off-campus services had been reviewed.

Interview on 11/3/16 at 10:00 a.m. with safety and quality improvement director H revealed they only had two to three contracted services. that was why there had been no review of those services. She stated they kept a list of businesses and accounts the provider had contracted to for its services. They did not have a list of outside contractors they were currently using for the provider.

Continued interview with administration revealed a contract could not be located at the time of survey for the following:
*Reprocessing of medical equipment by Stryker.
*Housekeeping services at the dermatology and orthopedic clinics.
*Medical waste disposal.
*Emergency water supply.
*Food Services of America for dietary.
*Medical gas and oxygen.
*Fire and life safety maintenance for the automatic sprinkler and fire alarm system.

On 11/2/16 at 3:00 p.m. a policy for requested outside service contractors was requested from administration. No policy was provided at the end of survey for outside contracted services and review of those services.

Based on observation, interview, and patient's admission packet review, the provider failed to ensure personal privacy was maintained for two of two observed patients (28 and 29) and one of one unobserved unidentified patient who received outpatient intravenous (IV) infusion therapy. Findings include:

1. Observation on 11/2/16 at 7:45 a.m. in the outpatient infusion therapy room revealed:
*There had been three separate areas set-up for patients to have received IV infusion therapy.
*Those three areas had been:
-Separated with small divider walls on the sides.
-Open in the front and faced the entrance door.

Observation on 11/2/16 of registered nurse (RN) G in the infusion room revealed:
*At 7:55 a.m. patient 28 had arrived for IV infusion therapy.
*The nurse had:
-Assisted patient 28 into one of the separated areas in the IV infusion room.
-Gathered all of the necessary supplies and medication to start that IV infusion for the patient.

Continued observation on 11/2/16 of RN G in the infusion room revealed:
*At 8:00 a.m. patient 29 had arrived in a wheelchair with his daughter.
*The nurse had:
-Assisted patient 29 into one of the other separated areas in the IV infusion room.
-Provided a chair for the daughter to sit in. That chair had been placed by the opened entrance door and directly across from patient 28's area.

Observation on 11/2/16 from 8:05 a.m. through 8:30 a.m. of RN G and patient 29 revealed:
*The daughter had voiced several concerns regarding her father with the nurse. Some of those concerns had been:
-He continued to receive chemotherapy for his cancer and was getting weaker.
-He had fallen twice within the past twenty-four hours.
*The nurse proceeded to:
-Check the patient's vital signs and listen to his lung sounds.
-Visit with the daughter regarding the results of her assessment. The patient's blood pressure had been low, and she was going to call the physician for some IV fluids.
-Gather all of the necessary supplies and medication to start his IV therapy.
*All of the above concerns voiced by the daughter and the nurse regarding patient 29 had been within hearing and visual capability of patient 28.

Interview on 11/2/16 at 8:35 a.m. with RN G revealed:
*She had agreed:
-The IV infusion therapy room had offered no privacy for the patients when receiving their treatment.
-There had been no sound barrier in the room to ensure privacy had been maintained.
-All conversations and voiced concerns regarding the patients were within the hearing capability of other patients and family members.
*She had stated:
-"I have another patient who comes in for IV therapy who has a horrible cough. She is very embarrassed about this and will ask for extra privacy."
-"We have had several conversations regarding the privacy in this room but nothing happens or changes."

Interview on 11/2/16 at 11:30 a.m. with safety and quality improvement director H revealed:
*She confirmed the above observations and interview with RN G.
*They had:
-Been aware of the privacy concerns in the IV infusion therapy room for two years.
-Not made any changes or recommendations regarding those privacy concerns.

Interview on 11/3/16 at 8:15 a.m. with the director of nursing confirmed the above observations and interviews with RN G and the safety and quality improvement director H.

Review of the provider's 2016 Patient Rights and Responsibilities pamphlet given to the patients upon admission revealed:
*"Your rights as a patient, you can expect:
-Personal privacy subject to the facility's ability to provide adequate medical and nursing care.
-Confidential treatment of your medical records and other medical information, unless otherwise required by law, unless you consent to the release of this information, or unless the disclosure is required to provide continuity of care for you."

Based on record review, interview, and policy review, the provider failed to ensure a complete documented quality assurance performance improvement (QAPI) program for the main hospital and seven of seven off campus services (Spearfish Regional Medical Clinic, Regional Rehabilitation, Regional Surgery Center, Queen City Regional Medical Clinic, Regional Orthopedics, Regional Dermatology, and Regional Rehabilitation [Belle Fourche) was re-implemented and improved upon for 2015 and carried through for 2016. The original QAPI program had been dropped when the provider created another quality assurance program in effect. Findings include:

1. Interview on 11/3/16 at 10:00 a.m. with director of safety and quality H and the performance improvement (PI) coordinator revealed:
*She was responsible for the facility and for the seven off-campus services (Spearfish Regional Medical Clinic, Regional Rehabilitation, Regional Surgery Center, Queen City Regional Medical Clinic, Regional Orthopedics, Regional Dermatology, and Regional Rehabilitation [Belle Fourche) QAPI programs.
*The last multi-disciplinary PI meeting was held 2/26/15.
*After that meeting a new restructured QAPI plan was started.
*No multi-disciplinary or departmental PI meetings had been held since that time.
*The first QAPI meeting using the new restructured QAPI plan would not be held until January 2017.
*From 2/26/15 to 11/3/16 nine different committees (surgical services, trauma, ambulatory care, OB/PEDS, pharmacy and therapeutics, infection control, acute care, and utilization review) selected PI projects.
-Those PI projects were presented to the medical executive committee at various times for review and input during the above time period.

Review of the quarterly medical executive committee meeting minutes from January 2015 through October 2016 revealed no information or recommendations in regards to any QAPI for the hospital or the off-campus services. Nor was there any specific information from the above mentioned nine committee PI projects.

Review of the provider's undated QAPI policy revealed:
*The hospital would measure and analyze indicators that included medical errors and adverse patient events to identify trends and provide justification for PI actions.
*Areas for improvement would have been selected based on:
-Likelihood to affect health outcomes, patient safety, and quality of care.
-Conditions of participation in Medicare.
*Prioritization of PI activities would have been based on:
-Processes that occurred in high-risk, high volume, problem prone areas or areas with the potential for severe adverse outcomes.
-Processes identified by multidisciplinary committees, medical executive committee, executive management team, or the quality committees.
*Reporting/Communication was provided to the executive management, medical executive committee, and the quality committees as indicated:
-Progress on PI initiatives, as well as applicable quality data by department representatives at the multidisciplinary PI committee.
*Documentation:
-Each department or individual PI team was responsible for maintaining its own data and documentation of progress.
-Multidisciplinary PI committee minutes would be maintained by the PI coordinator and shared with departments.
*Administrative and medical staff leaders were to have:
-Approved a facility wide PI plan..
-Reviewed and participated in the PI projects.

Based on observation, label review, and interview, the provider failed to ensure:
*Staff had put an opened date and their initials on multi-dose vials when opened in two of two patient care areas (dermatology clinic and orthopedic clinic).
*Single-use medication vials were not used for more than one patient in one of one clinic (dermatology).
Findings include:

1. Observation on 11/2/16 at 2:30 p.m. at the dermatology clinic nurses station revealed:
*An opened vial of lidocaine 1%.
*An opened single-use vial of sodium bicarbonate 8.4%.
*There was no date when those vials had been opened and first accessed.

2. Observation on 11/2/16 at 3:30 p.m. at the orthopedic clinic nurses station revealed:
*An opened vial of Sensorcaine 0.5%.
*An opened vial of lidocaine 1%.
*There was no date when those vials had been opened and first accessed.

3. Interview on 11/2/16 at 2:30 p.m. with the director of ambulatory services, histotechnician K, and registered nurse (RN) P confirmed the above findings.
*The director of ambulatory services and histotechnician K agreed a single-use vial of medication should not have been used for multiple patients in the dermatology clinic.
*RN P agreed opened vials of medication should have been initialed and dated when opened in the orthopedic clinic.

Interview on 11/3/16 at 8:30 a.m. with the director of pharmacy services revealed she did not:
*Include the dermatology and orthopedic clinics in the services that pharmacy provided.
*Have a policy that addressed the initialing and dating of opened vials of medication.
*Have a policy that addressed the use of a single-use vial having been used for multiple patients.

20031

A. Based on observation, testing, and interview, the provider failed to ensure cleanable, durable surfaces and/or cleanliness was maintained in ten of ten areas:
*Obstetrics.
*Dermatology clinic.
*Operating room (OR) one at the surgery center.
*OR two at the surgery center.
*Suture supply shelves at the surgery center.
*Surgical case container storage shelves at the surgery center.
*OR 3 at the hospital.
*Equipment storage room of the OR suite at the hospital.
*The housekeeping closet in the medical/surgery (med/surg) area.
*The supply closet at the north end of the med/surg area across from patient room 118.
Findings include:


Surveyor: 26632
1. Observation on 10/31/16 from 3:30 p.m. through 4:20 p.m. of the obstetrical area revealed the following items with uncleanable surfaces:
*Eight of eight bedside tables with clear finish had worn bare wood areas on the tops and drawer fronts.
*Eight of eight headboards with clear finish had worn and bare wood areas.
*Eight of eight bassinet bases with clear finish had worn and bare wood areas.
*Seven of seven delivery supply carts with clear finish had worn and bare wood areas.
*One of one hearing screening cart with clear finish had worn and bare wood areas.
*One of one wooden cart in the patient galley had chipped laminate wood. That cart held dishes and trays.
*One of one unpainted, unsealed peg board in the clean supply room. The peg board was used to hold sterile packaged surgical instruments.
*Metal binder clamps were used to hold packages of sterile packaged surgical instruments in the clean supply room. Those instruments were hung from the unpainted peg board.
*The fronts of the cupboards and drawers by the handwashing sinks in the surgery center's eight of eight patient rooms (201, 202, 203, 204, 205, 206, 207, and 208).

Interview on 10/31/16 at 4:30 p.m. with registered nurse (RN) J revealed she:
*Was aware of the condition of all the above items.
*Was going to put in a budget request to have the items replaced next year.

2. Observation on 11/1/16 from 7:00 a.m. through 10:30 a.m. at the surgical center revealed the following items with uncleanable surfaces:
*A linen cupboard in OR one with raw particle board showing on the edges of the door and frame.
*The two clean supply storage cupboards in OR two had raw particle board edges, cracked and missing laminate countertop edges.
*The front edge of the suture supply shelves had exposed bare wood.
*The front edge of the surgical case container shelves had exposed bare wood.
*Metal binder clamps were used to compress and hold sterile packaged urinary catheter packages.
*Both intake air grates in both OR one and two had chipped and peeling paint. The bare metal was exposed on over fifty percent of those grates.
*The edges, fronts, and backs of both OR one and two's doors had deep gouges in the wood. Those gouges created an uncleanable surface and were hazardous due to wooden splinters.

Interview on 11/1/16 at 10:45 p.m. with RN L revealed she:
*Was aware of the condition of the above items.
*Had sent many maintenance requests, but those items were rarely fixed.

Interview on 11/2/16 at 9:00 a.m. with maintenance person R revealed he:
*Was responsible for the maintenance at the surgical hospital.
*Had a monthly preventative maintenance checklist.
*That monthly checklist had not included doors, walls, and ceilings.
*Thought a bid had been placed for new cupboards. But he was unsure how long ago.
*Had sanded down the edges of the doors in other parts of the surgical center but not the OR doors.
*Had a system where all maintenance requests went through the maintenance supervisor and then a work list was created.
*He did not personally receive the maintenance requests.

Interview on 11/3/16 at 7:45 a.m. with surgery supervisor B revealed she also oversaw central sterilization. She revealed they used the Association of the Advancement of Medical Instrumentation (AAMI) guidelines. She had no policy on the storage of individual packages of instruments.

Review of the 2015 AAMI guidelines revealed packages should not be bent, compressed, or punctured. (Refer to finding two)

3. Observation and interview on 11/2/16 at 2:45 p.m. with director of ambulatory services I and histotechnician K at the dermatology clinic revealed the following items with uncleanable surfaces:
*Two of two patient bathroom vanities with unsealed wood on the sides and doors.
*The shelves in the housekeeping closets had unsealed wood.
*They agreed with those findings.


Surveyor: 20031
4. Observation on 11/1/16 from 1:40 p.m. to 4:00 p.m. revealed:
*The north wall of OR 3 had a one foot by six inch area of peeled/chipped paint and damaged gypsum board. The white fire extinguisher cabinet in OR 3 had several areas of missing paint giving it a polka dot look. Interview with surgery supervisor B at the time of the observations confirmed those findings. She stated she had thought a white board had been attached to the wall at one time and then removed. She also stated the extinguisher cabinet had been in that condition for a long time.
*The east wall of the equipment storage room of the OR suite had a hole in the gypsum board about the size of a softball. That hole appeared to be from the door closer. Interview with surgery supervisor B at the time of the observation confirmed that finding. She stated she was not aware of the hole in the wall.

5. Observation on 11/2/16 from 2:30 p.m. to 4:00 p.m. revealed:
a. The med/surg housekeeping closet had:
*Chipped and broken floor tiles.
*A black substance that appeared to be mold around the base of the floor sink.
*Bulged, warped, and chipped particle board shelves that were not cleanable.
*Chipped, gouged, and dirty walls.
Interview with housekeeper U confirmed those findings. She agreed the closet was "in need of help, but housekeeping was always last on the list when it came to repairs."
b. The storage closet across from patient room 118 had:
*Unsealed wooden shelves.
*An unshielded fluorescent light bulb.
*An unpainted area the size of a salad plate on the ceiling. The area appeared to be where an old light fixture had been installed.
*The following patient care items were placed haphazardly on the shelves or on the floor:
-Clean towels, single unprotected diapers, single unprotected adult briefs, a back board, wash basins, and rolls of self-adherent wrap.
*Interview with housekeeper U confirmed that finding.
*She stated that particular closet was used by nursing, and "it appears no one takes ownership for the cleaning and organization of the closet."

On 11/2/16 at 3:00 p.m. a policy regarding the integrity and/or cleanliness of patient use areas or items was requested from administration. However, none was provided at the end of survey.

B. Based on observation and interview, the provider failed to store cleaners and/or chemicals separately from patient use items in four of four areas (main housekeeping supply room, emergency room (ER) dirty utility room, dermatology clinic, and the orthopedic clinic). Findings include:

1. Observation on 11/2/16 from 2:30 p.m. to 4:00 p.m. revealed the main housekeeping supply area and the ER dirty utility supply cabinet had cleaners and/or chemicals stored intermingled and/or directly next to paper towels, toilet paper, and facial tissue. Interview with housekeeper U at the time of the observations confirmed those findings. She stated she was not aware cleaners and/or chemicals should not be stored with patient contact items.

Surveyor: 26632
2. Observation and interview on 11/2/16 at 2:45 p.m. with the director of ambulatory services and histotechnician K at the dermatology clinic revealed the main housekeeping supply area had cleaners and/or chemicals stored intermingled and/or directly next to paper towels, toilet paper, and facial tissue. Both of the patient bathroom cabinets had toilet paper stored under the drain lines. They agreed those items could have been contaminated if they became wet with chemicals or gray water from the drain line.

3. Observation and interview on 11/2/16 at 3:45 p.m. with the director of ambulatory services and RN P at the orthopedic clinic revealed the housekeeping supply area had cleaners and/or chemicals stored intermingled and/or directly next to paper towels, toilet paper, and facial tissue. They agreed those items could have been contaminated if they became wet with chemicals.

4. On 11/2/16 at 3:00 p.m. a policy regarding the storage of patient care items items was requested from administration. However, none was provided at the end of survey.

The lack of a preventative maintenance program, inadequate work orders from staff, and lack of any environmental rounding created a systemic effect that resulted in the hospital's inability to ensure a safe and clean environment for patients at the main facility and seven off campus services:
*Spearfish Regional Medical Clinic.
*Regional Rehabilitation.
*Regional Surgery Center.
*Queen City Regional Medical Clinic.
*Regional Orthopedics.
*Regional Dermatology.
*Regional Rehabilitation (Belle Fourche).

Based on observation, label review, testing, interview, document review, and policy review, the provider failed to ensure the following:
*Obstetrics department: hinged instruments (scissors and forceps) were sterilized in the opened position.
*The six post-operative care bays: sharps and waste containers were installed.
*X-ray area: the one gurney pad did not have spider web cracks and threadbare surfaces.
*Throughout the facility:
-Disinfectants used throughout the facility were used according to manufacturers' directions.
-Patient care items (baby diapers and adult briefs) were protected from possible contamination.
-All ice machines and water dispensers were descaled and cleaned to prevent possible contamination.
*Operating room equipment: seven pieces (two IV poles, two cautery carts, one Medtronic Collator, one electrocautery machine, and one Sonosite Ultrasound) were maintained in a cleanable condition.
*Post acute care unit (PACU): two handwashing sinks provided a sufficient amount of water for proper hand hygiene.
*Central sterilization (CS): one clean linen cart on the clean side of central sterilization was cleanable and could be disinfected.
*Medical/Surgical unit: one whirlpool tub was kept clean and patient care items in that tub room were kept clean, protected, and organized.
*Seven of seven bulk laundry bins containing soiled linen were stored in a soiled linen or trash room.
*Personal protective coverings and eyewear were used when collecting soiled linen and trash throughout the facility.
*Proper instruction and guidelines were given to all cardiac rehabilitation patients who used all the CardioRehab machines.
*The housekeeping closets in the dermatology and orthopedic clinics had cleaning products that would have been effective for the disinfection of surfaces and floors.
Findings include:

Surveyor: 26632
1. Observation on 10/31/16 at 4:15 p.m. in the obstetrical clean supply room revealed the following hinged surgical instruments in a closed position:
*Two iris scissors.
*Two Mayo scissors.
*Eleven large ring forceps.
*Two small ring forceps.
*Four Magills.
*One Allis clamp.

Interview on 10/31/16 at 4:30 p.m. with registered nurse (RN) J confirmed the hinged surgical instruments were not in a closed position. The sterility of those instruments could not have been guaranteed.

Interview on 11/3/16 at 7:45 a.m. with surgery supervisor B revealed she also oversaw central sterilization. She stated staff had been instructed to place hinged instruments in the opened position before sterilization. She revealed they did not use any type of positioner to hold the instruments open. She could not verify if they remained open during the sterilization process. She also revealed they used the Association of the Advancement of Medical Instrumentation (AAMI) guidelines. She had no policy on the sterilization of individualized packages of instruments.

Review of the 2015 AAMI guidelines revealed:
*The scrub person should ensure hinged instruments were opened for proper sterilization.
*Packages should not have been bent, compressed, or punctured.

Surveyor 32355:
2. Observation on 11/1/16 at 6:45 a.m. of RN E with patient 34 revealed she did the following:
*Gathered supplies to perform two intravenous (IV) insertions for fluid and medication administration.
*Returned to patient 34's care area with those supplies. The supplies had been inside of a disposable paper cloth.
*Placed the paper cloth containing the supplies directly on the patient's lap. Those supplies included an IV needle, gauze, and the IV site cleaning solution.
*After she had started an IV in the patient's left hand she took all of her soiled supplies and left the room with them.
*Took those supplies to the staff work station across from the patient's care area.
*Disposed of the needle into the sharps container sitting on the work station.
*Placed the rest of the used supplies inside of a garbage can underneath of the work station.
*Sanitized her hands and returned to the patient's care area.
*Had repeated the same procedure as above on the patient's right hand.
*Had crossed an area containing a high volume of patients and staff to dispose of the hazardous waste and garbage.

Observation on 11/1/16 at 8:00 a.m. of the post-operative bay area revealed:
*There had been six patient care areas.
*No hazardous sharp waste containers were in those six patient care areas.
*No garbage cans to dispose of the hazardous soiled items and used items.

Interview on 11/1/16 at 8:25 a.m. with RNs C and E revealed:
*The above observation for starting IVs and disposing of the waste had been their usual practice.
*They agreed:
-All hazardous waste and soiled/used items had to leave the patient care area for disposal.
-Their process had not been sanitary and created the potential for cross-contamination of bacteria or other microorganisms to other patients and staff.
-There should have been biohazardous sharps waste containers and garbage cans in all six of the patient care areas.

Interview on 11/4/16 at 8:15 a.m. with the director of nursing revealed:
*She had not been aware there were no sharps containers or garbage cans located in the post-operative bays.
*She agreed that had created an unsanitary environment with the potential of cross-contamination of bacteria or other microorganisms.
*They used the Association of peri-Operative Nurses (AORN) guidelines and Centers for Disease Control (CDC) guidelines.

Interview on 11/4/16 at 9:35 a.m. with environmental services supervisor F revealed:
*The housekeeping department was responsible to ensure sharps containers and garbage cans had been placed in all appropriate patient care areas.
*She had not been aware there were no sharps containers or garbage cans located in the post-operative bays.
*She agreed all six of those patient care areas should have had the proper waste products available for the staff to use.

According to 2016 AORN guidelines under patient and worker safety, titled Sharps Safety, page 429, revealed "Accessibility criteria for a sharps disposal container should include that:
*The container is placed in close proximity to the point of use,
*There is an obstacle-free pathway between the point of use and the container; and
*The container is reachable by personnel of varied heights."

Review of the provider's January 2005 Non-Infectious Waste Disposal policy revealed "Noninfectious waste will be disposed of in a safe and appropriate manner."

3. Observation on 11/1/16 at 2:30 p.m. with surgical supervisor B in the post-acute care unit (PACU) revealed:
*There had been an x-ray gurney located in one of the patient care areas.
*The pad on that gurney had multiple areas of spider web cracks and threadbare areas.
*They had tried to replace the pad but could not find the proper size to fit the gurney.
*She agreed:
-Those threadbare areas had not been cleanable and created an unsanitary environment.
-She agreed that had created an unsanitary environment with the potential of cross-contamination of bacteria or other microorganisms.

Review of the 2016 AORN guidelines under Environmental Cleaning, page 12 revealed "mattresses and padded positioning devices surfaces (eg, OR beds, arm boards, patient transport carts) should be moisture-resistant and intact. Absorbent or non-intact surfaces may become reservoirs for microorganisms and may harbor pathogens."



20031

4. Observation and interview on 11/1/16 at 10:40 a.m. revealed housekeeper A was cleaning a drinking fountain by the medical/surgical (med/surg) wing. She used Oxivir to wipe down all surfaces, as it was a disinfectant. She proceeded to wipe all areas of the fountain including the spigot. She stated she used Oxivir in the food pantries/kitchenettes throughout the facility.

Interview on 11/2/16 at 2:30 p.m. with housekeeper U revealed she also used Oxivir on all surfaces throughout the facility. She confirmed other housekeepers had been trained to use Oxivir on all areas but the floors.

Interview on 11/4/16 at 9:35 a.m. with environmental services supervisor F revealed:
*She confirmed the information from the interviews with housekeepers A and U.
*Neither she nor her staff were aware Oxivir was not a food grade sanitizer and should not have been used in the food pantries/kitchenettes or on the drinking fountains.

5. Interview on 11/1/16 at 2:00 p.m. with certified surgical technician (CST) D revealed:
*Sometimes CSTs would help the housekeeper assigned to the operating room (OR) suites.
*Between surgical cases he would use the product labeled for surfaces that was in the housekeeping closet of the OR suite.
*When questioned about the contact times for the disinfectant he stated "I think three minutes?"
*He then wiped down the surgical table and the surface remained wet for approximately 45-60 seconds.
*He did not apply more product but stated, "The disinfectant is on the surface for more than three minutes."

Review of the products in the OR housekeeping closet revealed the Twist 'N Fill system for the chemicals had handwritten labels for the containers. The handwritten note marked Mop Bucket had the Oxivir disinfectant in it. The other disinfectant Virex-Plus was placed in the adjacent slot. Review of the labels on those disinfectants revealed the Oxivir disinfectant was for surfaces and the Virex-Plus was for the floors.

Interview on 11/2/16 at 3:30 p.m. with CST D revealed neither the housekeepers nor the environmental supervisor trained the CSTs on the disinfectants. He stated other CSTs who had been there longer trained the newer CSTs.

Interview on 11/4/16 at 9:35 a.m. with environmental services supervisor F revealed:
*She confirmed Oxivir was the surface disinfectant, and Virex-Plus was the floor disinfectant.
*She was not aware the Twist 'N Fill system had been filled with the incorrect containers.
*She was not aware who trained the CSTs to help the OR housekeeper.

Review of the Oxivir label revealed:
*Let solution remain on surface for a minimum of five minutes.
*Non-food contact sanitizer in three minutes.

Combined interviews during the survey from 11/1/16 through 11/4/16 revealed two housekeepers, A and U, CST D, and environmental supervisor F, answered the contact time was three to five minutes. But none of them could give a definite use for the three minutes versus the five minutes regarding a specific area.

6. Observation on 11/1/16 from 1:40 p.m. to 4:00 p.m. revealed:
*Two of two intravenous (IV) poles were rusted at the flexible height adjustment seam.
*Two of two Triad Cautery Carts had chipped paint.
*One of one Medtronic Collator had chipped paint with rust spots the size of dimes and quarters.
*One of two electrocautery machines had a taped paper sign approximately one foot by one foot on top of the machine, the tape was frayed.
*One of one Sonosite Ultrasound machine had taped paper directions on it in two different areas.

Interview at the time of the above observation with surgery supervisor B, RN C, and certified registered nurse anesthetist supervisor S confirmed those findings. They agreed the rusted, chipped paint surfaces, and the taped paper directions were not cleanable.

7. Observation and testing on 11/1/16 at 3:00 p.m. of the two hand sinks in PACU revealed:
*A very small stream of water would run from the spigot.
*That small stream of water produced approximately one cup of water every twenty to thirty seconds.
*That stream would not provide enough force to remove gross contaminants from the hands for hygienic handwashing.

Interview with surgery supervisor B and RN C at the time of the above testing and observation confirmed that finding. RN C stated she had submitted multiple work orders over the last five months to have the sinks fixed. She stated plant operations would come and check the sinks and would tell them there was nothing they could do.

8. Observation and interview on 11/1/16 at 3:00 p.m. with CST R revealed a canvas cart with a wooden support frame and drain hose in the clean side of the central sterilization room. That cart was used to transport the clean hand towels to a sterile area. She stated the cart had been used since she had been in CS for over three years. She confirmed they used those hand towels in surgery to wipe up gross spills. She also confirmed the cart was not cleanable and could not have been disinfected.

9. Observation and interview on 11/2/16 from 2:30 p.m. to 4:00 p.m. with housekeeper U revealed:
a. A tub room with a whirlpool tub.
-The tub was dusty and could be wiped clean with a brush of the hand. *Two plastic totes contained items that included:
-Athletic tape, gait belts, tub chair straps, combs, face towels, toothpaste, and a toothbrush.
*"I am embarrassed for the condition of this room. The tub should be cleaned by the housekeepers daily."
*She was not to move or clean patient care items.

Interview on 11/2/16 at 2:40 p.m. with nurse manager V revealed she was not aware of the condition of the tub room. She stated it should be kept clean and organized and patient care items should be kept clean, protected, and organized.

b. A self-dispensing ice machine in the clean supply room of the med/surg wing.
*The ice and water chutes of the machine were encrusted inside and outside with white scale.
*She confirmed the condition of the machine and stated all the ice and water machines throughout the hospital were in that same condition. *Neither housekeeping nor dietary cleaned the machines, as they were on a contract with a commercial refrigeration service.
*She agreed it appeared the machine had not been cleaned or delimed in a long time.

Interview on that same day at 4:30 p.m. with the executive assistant revealed a current contract with the commercial refrigeration company could not be located.

c. Several individual baby diapers and adult briefs were unprotected in trays in the clean supply room of the med/surg area.
*Housekeeping did not supply the above items for the shelves in patient areas.
*She also confirmed the diapers and the adult briefs were individualized in all department clean supply rooms.

Interview during the above time with materials management person W revealed materials management delivered all clean, protected patient care items enclosed in the original packaging to all departments. She also confirmed the baby diapers and adult briefs were stored unprotected in bins in all departments. "Clean underwear were individually packaged in plastic bags, so it's confusing why some articles are protected and nursing staff removes others from their covers."

d. Seven large (approximately 150 gallon) plastic rolling carts were stored without covers or lids in the basement hall directly outside of materials management and the clean linen room.
*Those large carts were used to store soiled linen for all the departments of the hospital.
*They were completely full at times before an outside source picked them up.
*The soiled linen bags were:
-Made of a cloth like material.
-There had been times when unidentified liquid or gelatinous substances from the OR and ER would leak through those cloth bags.
*Interview with housekeeper U revealed she and other housekeepers were not provided with personal protective gear to wear when they picked up soiled linen.



26632

10. Observation and interview on 10/31/16 at 4:30 p.m. with RN J in the obstetrical area revealed:
*A galley kitchen for patient use.
*There was a water and ice dispenser for patient/guest use.
*The splash area of the water dispenser had a brown discoloration on the inside.
*The catch tray had a moderate build-up of mineral deposits.
*She stated the dietary department was responsible for the cleaning of the water/ice machine.

11. Observation and interview on 11/1/16 at 10:00 a.m. with RN L of the surgical center kitchen revealed:
*A self-dispensing ice/water machine had a moderate amount of mineral build-up in the splash areas and the collection tray.
*She was unsure of who was responsible for the cleaning of the ice/water machine.

12. Observation and interview on 11/2/16 at 10:45 a.m. with exercise physiologists X and Y in the cardiac rehabilitation room revealed:
*A corroded water fountain spigot.
*The water fountain surface had a spotty and stained appearance.
*They were not aware of who cleaned and sanitized the water fountain and agreed it appeared soiled.
*Multiple treadmills, stationary bicycles, stair stepping, and elliptical machines were in use.
*The areas on those exercise machines were sanitized with a Super Sani-Cloth wipe by each patient after use.
*Those wipes were located in various places throughout the cardiac rehabilitation room.
*Above each of the wipe stations a sign stated to clean each machine after the patient was finished.
*The patients were to have wiped down the machines with the sanitizing wipes.
*Exercise physiologists X and Y were not aware of how long the surface sanitizer should have remained wet.
*They did not monitor the patients to ensure the correct wipe down procedure had been completed.
*Exercise physiologist X stated they would not have had time to wipe down each machine after the patient had completed their exercise.
*She stated there was hand sanitizer for each patient to use before and after they used the equipment.
*They agreed they did not monitor if the patients had actually used the hand sanitizer before and after using the exercise equipment.

13. Observation and interview on 11/2/16 at 2:45 p.m. and 3:45 p.m. with director of ambulatory services I revealed:
*The housekeeping closets in the dermatology and orthopedic clinics had no cleaning products that would have been effective for the disinfection of surfaces and floors.
*There was a contracted housekeeping service for the dermatology and orthopedic clinics.
*She was unsure of what cleaners and disinfectants had been used in those clinics.
*She agreed those clinics should have had products that were disinfectants and not cleaners for the surfaces and floors.

14. Review of the provider's December 2015 Equipment Cleaning Storage and Maintenance policy revealed:
*Non-disposable items used should have been disinfected using hospital approved cleaning agents between patient use.
*Maintenance work orders should have been entered into the computer and a copy attached to the equipment.

Polices and/or procedures requested on 11/2/16 at 4:00 p.m. but not provided by the provider included:
*Directions, guidelines, and tasks for housekeeping and/or cleaning personnel.
*Integrity of OR equipment.
*Cleanability of central sterilization equipment.
*Maintenance of self-dispensing ice and water machines.
*Protection and storage of patient care items.
*Bulk storage and handling of soiled linen.


Review of the 2015 AORN guidelines revealed:
*The perioperative RN should assess the perioperative environment frequently for cleanliness and take action to implement cleaning and disinfection procedures.
*Disinfectants should be applied and reapplied as needed per manufacturers' instructions.
*Mattresses and padded positioning device surfaces should be moisture resistant and intact.
*Damaged or worn coverings should be replaced.
*All refrigerators and ice machines in patient care areas should be cleaned and disinfected on a routine basis.
*Laundry contaminated with blood, body fluids, or other potentially infectious materials must be handled as little as possible.
*Contaminated laundry that was wet and might soak or leak through the container or bag must be placed and transported in containers or bags that prevent soak-through or leakage of fluids to the exterior.
*Healthcare personnel handling contaminated items or cleaning contaminated surfaces must wear personal protective equipment (PPE) to reduce the risk of exposure to blood, body fluids, and other potentially infectious materials.

Based on observation, interview, policy review, and manufacturer's recommendation review, the provider failed to ensure:
*The dermatology clinic's medical instrument sterilization procedure room was operated and constructed appropriately and according to sterilization guidelines.
*A handwashing sink was available in the sterilization room at the dermatology clinic.
*Cidex OPA was used appropriately, according to manufacture's directions, and according to sterilization guidelines in the wound care/foot clinic patient area of the main facility.
Findings include:

1. Observation on 11/2/16 from 2:15 p.m. through 2:45 p.m. of the dermatology clinic's sterilization area revealed:*A small room that contained a laundry sink, counter, and a Midmark M11 autoclave.
*The cover for the above sink was held open by a hook and eye. The top of the cover was laminate, and the underside was raw particle board.
*There was no handwashing sink, hand towels, or hand soap.
*There were blue surgical towels that covered the surface of the countertop.

Interview on 11/2/16 at 2:45 p.m. with director of ambulatory services I, histotechnician K, and clinical assistant M revealed:
*They were aware there should have been a separate room for cleaning soiled instruments and packaging clean instruments prior to sterilization.
*They did not have any plans to separate the room into two areas as soiled and clean.
*The soiled instruments were cleaned in the laundry sink with an enzymatic cleaner, rinsed, dipped in a lubricant, and then placed on the blue surgical towels to dry.
*The blue surgical towels were changed daily.
*The laminate countertop was cleaned daily with Speed-Clean. They agreed that was not a disinfectant.
*There had been a handwashing sink in the sterilization room, but it had been removed a few years ago and replaced with the laundry sink.
*They agreed:
-The raw particle board on the underside of the cover for the sink was not a cleanable surface.
-The sink cover was not used and was always in the raised position exposing the raw particle board.
-Water and enzymatic cleaner splashed onto the raw particle board.
*The paper towels and hand soap had been removed when the handwashing sink had been removed.

Interview on 11/3/16 at 7:45 a.m. with surgery supervisor B revealed she also oversaw central sterilization. She stated she did not oversee the outlying clinics and their sterilization techniques. She also revealed they used the Association of the Advancement of Medical Instrumentation (AAMI) guidelines. She also stated she had no policy on the sterilization of individualized packages of instruments.

Review of the 2015 AAMI guidelines revealed:
*Functional work areas should be physically separated by walls or partitions.
*Washing facilities should be conveniently located to promote hand washing.
*Surface areas should be easily cleanable.

2. Observation on 11/2/16 from 11:30 a.m. through 12:15 p.m. and again on 11/3/16 from 8:45 a.m. through 9:00 a.m. of the wound care/foot clinic revealed:
*A strong chemical odor in the patient care area, the patient waiting room, and the hallway outside the clinic.
*A glass container with a metal top was on the shelf of the two compartment sink.
*A metal instrument holder with a plastic cover held surgical scissors, tweezers, and forceps.
*A metal cart beside the sink with a gallon container of Cidex OPA and Cidex OPA testing strips.

Interview on 11/3/16 at 9:00 a.m. with registered nurse X revealed:
*She thought the chemical odor was from the disinfectant wipes that were used on the surfaces in the wound clinic.
*The Cidex OPA was used to disinfect instruments used during wound care procedures.
*The Cidex OPA solution was changed every day.
*The instruments were rinsed and scrubbed with water first, then immersed in the Cidex OPA solution for approximately ten minutes, rinsed in tap water, and placed in the instrument holder to dry.
*She used gloves when she did the disinfection process.
*There was no eye protection or gowns used during the disinfection process.

Review of the manufacturer's recommendations for the Cidex OPA solution revealed:
*HLD manual processing:
-"Immerse device completely in the Cidex OPA solution for a minimum of 12 minutes."
*Precautions:
-"Use Cidex OPA Solution in a well-ventilated area and in closed containers with tight fitting lids."
-"Contaminated reusable devices MUST BE THOROUGHLY CLEANED prior to disinfection."
*Warnings:
-"Avoid exposure to ortho-phthaladehyde vapors, as they may be irritating to the respiratory tract and eyes."
*User Training:
-"The user should be adequately trained in the decontamination and disinfection of medical devices and the handling of liquid chemical germicides."

Review of the provider's August 2014 High Level Disinfection (HLD) policy revealed:*Precautions:
-"Use gloves of an appropriate type and length, eye protection, and fluid resistant gowns."
-"Use HLD in a well-ventilated area in a closed container with a tight-fitting lid."
-"Follow facility practices or if manufacturer has specific written instructions for its reusable device when reprocessing in the HLD."
-"When reprocessing in the disinfectant make sure the item is completely immersed, lumens flushed and time for 12 minutes."

Review of the 2016 Association of periOperative Room Nurses guidelines revealed "Patients, visitors, and health care workers should be protected from injuries and illnesses caused by hazardous chemicals used in the facility."

20031

A. Based on observation, testing, and interview, the provider failed to ensure cleanable, durable surfaces and/or cleanliness was maintained in ten of ten areas:
*Obstetrics.
*Dermatology clinic.
*Operating room (OR) one at the surgery center.
*OR two at the surgery center.
*Suture supply shelves at the surgery center.
*Surgical case container storage shelves at the surgery center.
*OR 3 at the hospital.
*Equipment storage room of the OR suite at the hospital.
*The housekeeping closet in the medical/surgery (med/surg) area.
*The supply closet at the north end of the med/surg area across from patient room 118.
Findings include:


Surveyor: 26632
1. Observation on 10/31/16 from 3:30 p.m. through 4:20 p.m. of the obstetrical area revealed the following items with uncleanable surfaces:
*Eight of eight bedside tables with clear finish had worn bare wood areas on the tops and drawer fronts.
*Eight of eight headboards with clear finish had worn and bare wood areas.
*Eight of eight bassinet bases with clear finish had worn and bare wood areas.
*Seven of seven delivery supply carts with clear finish had worn and bare wood areas.
*One of one hearing screening cart with clear finish had worn and bare wood areas.
*One of one wooden cart in the patient galley had chipped laminate wood. That cart held dishes and trays.
*One of one unpainted, unsealed peg board in the clean supply room. The peg board was used to hold sterile packaged surgical instruments.
*Metal binder clamps were used to hold packages of sterile packaged surgical instruments in the clean supply room. Those instruments were hung from the unpainted peg board.
*The fronts of the cupboards and drawers by the handwashing sinks in the surgery center's eight of eight patient rooms (201, 202, 203, 204, 205, 206, 207, and 208).

Interview on 10/31/16 at 4:30 p.m. with registered nurse (RN) J revealed she:
*Was aware of the condition of all the above items.
*Was going to put in a budget request to have the items replaced next year.

2. Observation on 11/1/16 from 7:00 a.m. through 10:30 a.m. at the surgical center revealed the following items with uncleanable surfaces:
*A linen cupboard in OR one with raw particle board showing on the edges of the door and frame.
*The two clean supply storage cupboards in OR two had raw particle board edges, cracked and missing laminate countertop edges.
*The front edge of the suture supply shelves had exposed bare wood.
*The front edge of the surgical case container shelves had exposed bare wood.
*Metal binder clamps were used to compress and hold sterile packaged urinary catheter packages.
*Both intake air grates in both OR one and two had chipped and peeling paint. The bare metal was exposed on over fifty percent of those grates.
*The edges, fronts, and backs of both OR one and two's doors had deep gouges in the wood. Those gouges created an uncleanable surface and were hazardous due to wooden splinters.

Interview on 11/1/16 at 10:45 p.m. with RN L revealed she:
*Was aware of the condition of the above items.
*Had sent many maintenance requests, but those items were rarely fixed.

Interview on 11/2/16 at 9:00 a.m. with maintenance person R revealed he:
*Was responsible for the maintenance at the surgical hospital.
*Had a monthly preventative maintenance checklist.
*That monthly checklist had not included doors, walls, and ceilings.
*Thought a bid had been placed for new cupboards. But he was unsure how long ago.
*Had sanded down the edges of the doors in other parts of the surgical center but not the OR doors.
*Had a system where all maintenance requests went through the maintenance supervisor and then a work list was created.
*He did not personally receive the maintenance requests.

Interview on 11/3/16 at 7:45 a.m. with surgery supervisor B revealed she also oversaw central sterilization. She revealed they used the Association of the Advancement of Medical Instrumentation (AAMI) guidelines. She had no policy on the storage of individual packages of instruments.

Review of the 2015 AAMI guidelines revealed packages should not be bent, compressed, or punctured. (Refer to finding two)

3. Observation and interview on 11/2/16 at 2:45 p.m. with director of ambulatory services I and histotechnician K at the dermatology clinic revealed the following items with uncleanable surfaces:
*Two of two patient bathroom vanities with unsealed wood on the sides and doors.
*The shelves in the housekeeping closets had unsealed wood.
*They agreed with those findings.


Surveyor: 20031
4. Observation on 11/1/16 from 1:40 p.m. to 4:00 p.m. revealed:
*The north wall of OR 3 had a one foot by six inch area of peeled/chipped paint and damaged gypsum board. The white fire extinguisher cabinet in OR 3 had several areas of missing paint giving it a polka dot look. Interview with surgery supervisor B at the time of the observations confirmed those findings. She stated she had thought a white board had been attached to the wall at one time and then removed. She also stated the extinguisher cabinet had been in that condition for a long time.
*The east wall of the equipment storage room of the OR suite had a hole in the gypsum board about the size of a softball. That hole appeared to be from the door closer. Interview with surgery supervisor B at the time of the observation confirmed that finding. She stated she was not aware of the hole in the wall.

5. Observation on 11/2/16 from 2:30 p.m. to 4:00 p.m. revealed:
a. The med/surg housekeeping closet had:
*Chipped and broken floor tiles.
*A black substance that appeared to be mold around the base of the floor sink.
*Bulged, warped, and chipped particle board shelves that were not cleanable.
*Chipped, gouged, and dirty walls.
Interview with housekeeper U confirmed those findings. She agreed the closet was "in need of help, but housekeeping was always last on the list when it came to repairs."
b. The storage closet across from patient room 118 had:
*Unsealed wooden shelves.
*An unshielded fluorescent light bulb.
*An unpainted area the size of a salad plate on the ceiling. The area appeared to be where an old light fixture had been installed.
*The following patient care items were placed haphazardly on the shelves or on the floor:
-Clean towels, single unprotected diapers, single unprotected adult briefs, a back board, wash basins, and rolls of self-adherent wrap.
*Interview with housekeeper U confirmed that finding.
*She stated that particular closet was used by nursing, and "it appears no one takes ownership for the cleaning and organization of the closet."

On 11/2/16 at 3:00 p.m. a policy regarding the integrity and/or cleanliness of patient use areas or items was requested from administration. However, none was provided at the end of survey.

B. Based on observation and interview, the provider failed to store cleaners and/or chemicals separately from patient use items in four of four areas (main housekeeping supply room, emergency room (ER) dirty utility room, dermatology clinic, and the orthopedic clinic). Findings include:

1. Observation on 11/2/16 from 2:30 p.m. to 4:00 p.m. revealed the main housekeeping supply area and the ER dirty utility supply cabinet had cleaners and/or chemicals stored intermingled and/or directly next to paper towels, toilet paper, and facial tissue. Interview with housekeeper U at the time of the observations confirmed those findings. She stated she was not aware cleaners and/or chemicals should not be stored with patient contact items.

Surveyor: 26632
2. Observation and interview on 11/2/16 at 2:45 p.m. with the director of ambulatory services and histotechnician K at the dermatology clinic revealed the main housekeeping supply area had cleaners and/or chemicals stored intermingled and/or directly next to paper towels, toilet paper, and facial tissue. Both of the patient bathroom cabinets had toilet paper stored under the drain lines. They agreed those items could have been contaminated if they became wet with chemicals or gray water from the drain line.

3. Observation and interview on 11/2/16 at 3:45 p.m. with the director of ambulatory servi

Based on observation, label review, testing, interview, document review, and policy review, the provider failed to ensure the following:
*Obstetrics department: hinged instruments (scissors and forceps) were sterilized in the opened position.
*The six post-operative care bays: sharps and waste containers were installed.
*X-ray area: the one gurney pad did not have spider web cracks and threadbare surfaces.
*Throughout the facility:
-Disinfectants used throughout the facility were used according to manufacturers' directions.
-Patient care items (baby diapers and adult briefs) were protected from possible contamination.
-All ice machines and water dispensers were descaled and cleaned to prevent possible contamination.
*Operating room equipment: seven pieces (two IV poles, two cautery carts, one Medtronic Collator, one electrocautery machine, and one Sonosite Ultrasound) were maintained in a cleanable condition.
*Post acute care unit (PACU): two handwashing sinks provided a sufficient amount of water for proper hand hygiene.
*Central sterilization (CS): one clean linen cart on the clean side of central sterilization was cleanable and could be disinfected.
*Medical/Surgical unit: one whirlpool tub was kept clean and patient care items in that tub room were kept clean, protected, and organized.
*Seven of seven bulk laundry bins containing soiled linen were stored in a soiled linen or trash room.
*Personal protective coverings and eyewear were used when collecting soiled linen and trash throughout the facility.
*Proper instruction and guidelines were given to all cardiac rehabilitation patients who used all the CardioRehab machines.
*The housekeeping closets in the dermatology and orthopedic clinics had cleaning products that would have been effective for the disinfection of surfaces and floors.
Findings include:

Surveyor: 26632
1. Observation on 10/31/16 at 4:15 p.m. in the obstetrical clean supply room revealed the following hinged surgical instruments in a closed position:
*Two iris scissors.
*Two Mayo scissors.
*Eleven large ring forceps.
*Two small ring forceps.
*Four Magills.
*One Allis clamp.

Interview on 10/31/16 at 4:30 p.m. with registered nurse (RN) J confirmed the hinged surgical instruments were not in a closed position. The sterility of those instruments could not have been guaranteed.

Interview on 11/3/16 at 7:45 a.m. with surgery supervisor B revealed she also oversaw central sterilization. She stated staff had been instructed to place hinged instruments in the opened position before sterilization. She revealed they did not use any type of positioner to hold the instruments open. She could not verify if they remained open during the sterilization process. She also revealed they used the Association of the Advancement of Medical Instrumentation (AAMI) guidelines. She had no policy on the sterilization of individualized packages of instruments.

Review of the 2015 AAMI guidelines revealed:
*The scrub person should ensure hinged instruments were opened for proper sterilization.
*Packages should not have been bent, compressed, or punctured.

Surveyor 32355:
2. Observation on 11/1/16 at 6:45 a.m. of RN E with patient 34 revealed she did the following:
*Gathered supplies to perform two intravenous (IV) insertions for fluid and medication administration.
*Returned to patient 34's care area with those supplies. The supplies had been inside of a disposable paper cloth.
*Placed the paper cloth containing the supplies directly on the patient's lap. Those supplies included an IV needle, gauze, and the IV site cleaning solution.
*After she had started an IV in the patient's left hand she took all of her soiled supplies and left the room with them.
*Took those supplies to the staff work station across from the patient's care area.
*Disposed of the needle into the sharps container sitting on the work station.
*Placed the rest of the used supplies inside of a garbage can underneath of the work station.
*Sanitized her hands and returned to the patient's care area.
*Had repeated the same procedure as above on the patient's right hand.
*Had crossed an area containing a high volume of patients and staff to dispose of the hazardous waste and garbage.

Observation on 11/1/16 at 8:00 a.m. of the post-operative bay area revealed:
*There had been six patient care areas.
*No hazardous sharp waste containers were in those six patient care areas.
*No garbage cans to dispose of the hazardous soiled items and used items.

Interview on 11/1/16 at 8:25 a.m. with RNs C and E revealed:
*The above observation for starting IVs and disposing of the waste had been their usual practice.
*They agreed:
-All hazardous waste and soiled/used items had to leave the patient care area for disposal.
-Their process had not been sanitary and created the potential for cross-contamination of bacteria or other microorganisms to other patients and staff.
-There should have been biohazardous sharps waste containers and garbage cans in all six of the patient care areas.

Interview on 11/4/16 at 8:15 a.m. with the director of nursing revealed:
*She had not been aware there were no sharps containers or garbage cans located in the post-operative bays.
*She agreed that had created an unsanitary environment with the potential of cross-contamination of bacteria or other microorganisms.
*They used the Association of peri-Operative Nurses (AORN) guidelines and Centers for Disease Control (CDC) guidelines.

Interview on 11/4/16 at 9:35 a.m. with environmental services supervisor F revealed:
*The housekeeping department was responsible to ensure sharps containers and garbage cans had been placed in all appropriate patient care areas.
*She had not been aware there were no sharps containers or garbage cans located in the post-operative bays.
*She agreed all six of those patient care areas should have had the proper waste products available for the staff to use.

According to 2016 AORN guidelines under patient and worker safety, titled Sharps Safety, page 429, revealed "Accessibility criteria for a sharps disposal container should include that:
*The container is placed in close proximity to the point of use,
*There is an obstacle-free pathway between the point of use and the container; and
*The container is reachable by personnel of varied heights."

Review of the provider's January 2005 Non-Infectious Waste Disposal policy revealed "Noninfectious waste will be disposed of in a safe and appropriate manner."

3. Observation on 11/1/16 at 2:30 p.m. with surgical supervisor B in the post-acute care unit (PACU) revealed:
*There had been an x-ray gurney located in one of the patient care areas.
*The pad on that gurney had multiple areas of spider web cracks and threadbare areas.
*They had tried to replace the pad but could not find the proper size to fit the gurney.
*She agreed:
-Those threadbare areas had not been cleanable and created an unsanitary environment.
-She agreed that had created an unsanitary environment with the potential of cross-contamination of bacteria or other microorganisms.

Review of the 2016 AORN guidelines under Environmental Cleaning, page 12 revealed "mattresses and padded positioning devices surfaces (eg, OR beds, arm boards, patient transport carts) should be moisture-resistant and intact. Absorbent or non-intact surfaces may become reservoirs for microorganisms and may harbor pathogens."



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4. Observation and interview on 11/1/16 at 10:40 a.m. revealed housekeeper A was cleaning a drinking fountain by the medical/surgical (med/surg) wing. She used Oxivir to wipe down all surfaces, as it was a disinfectant. She proceeded to wipe all areas of the fountain including the spigot. She stated she used Oxivir in the food pantries/kitchenettes throughout the facility.

Interview on 11/2/16 at 2:30 p.m. with housekeeper U revealed she also used Oxivir on all surfaces throughout the facility. She confirmed other housekeepers had been trained to use Oxivir on all areas but the floors.

Interview on 11/4/16 at 9:35 a.m. with environmental services supervisor F revealed:
*She confirmed the information from the interviews with housekeepers A and U.
*N