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KAHUKU MEDICAL CENTER
INFECTION PREVENT SURVEIL & CONTROL OF HAIs
Tag No.: C1208
Based on observation and interviews, the facility failed to maintain a clean and sanitary environment to avoid sources of infection.
Findings include:
On 12/28/2021 at 10:47 AM, while conducting an inspection of Room #1 in the Emergency Room (ER) with the Director of Nursing (DON), Chief Nursing Officer (CNO), and Registered Nurse (RN)1 observed food crumbs and three (3) personal re-usable bags (blue/white; yellow; and black/white) on the patient gurney. The DON, CNO, and RN1 acknowledged the gurney was soiled with food crumbs and the bags on the gurney were staff's personal bags and confirmed the gurney in Room#1 was not kept in a clean and sanitary manner.
LEADERSHIP RESPONSIBILITIES
Tag No.: C1239
Based on staff observation, staff interview, review of training record, and review of policy, the facility failed to provide documentation of initial and/or annual competency-based training and education for staff that perform the sterilization of sterile procedural instruments.
Findings include:
During an observation of Phlebotomist (Phleb) 1 on 12/28/21 at 11:30 AM, Phleb 1 talked through the procedure for sterilizing sterile procedural instruments. Phleb 1 explained through the Pre-Cleaning, Cleaning, Inspection, Packaging for Sterilization, Peel Pack/Pouch, and Autoclave steps. However, when Phleb 1 was asked about initial training and also annual training/competencies, Phleb 1 said they could not locate any documentation of the training.
On 12/28/21 at 01:50 PM, the Director of Nursing (DON) who was also responsible for the Infection Prevention and Control program was queried about the missing documentation of initial training and/or annual competency-based training. DON stated that since the recent Joint Commission visit, they have not been able to locate any documentation of the training. DON added that the previous Infection Prevention and Control employee, who did the training, has since left. DON acknowledged that without any documentation, the initial and/or annual training could not be verified.
A review of facility policy titled Guidelines for Sterilizing of Patient Equipment states Purpose, Disinfection and sterilization are essential for ensuring that medical and surgical instruments do not transmit infectious pathogens to patients. Scope, this policy applies to all staff, volunteers, and contracted employees of Kahuku Medical Center who sterilize equipment. Policy, Kahuku Medical Center will ensure that all reusable medical equipment is properly sterilized. 1. Pre-Cleaning Phase ... 2. Cleaning Phase ... 4. Transportation to the Sterilization Room ... 5. Inspection Phase ... 6. Packaging with Peel Pack/Pouch for Sterilization ... 7. Sterilization Phase Autoclave ... 8. Immediate-use Steam Sterilization ... 9. Management / Steps of failed Biological monitor / Positive Biological Indicators ... 10. Transport of Sterilized Instruments ... 11. Storage of Sterile Instruments ... 12. Quality Control of Autoclave ...