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Based on observation, interview, and record review, the hospital failed to ensure the QAPI program identified opportunities for improvement and implemented changes that would lead to improvement in the physical environment in the perio-perative areas and the ED as evidenced by:

1. Multiple areas needing repair in the perioperative areas previously identified by the hospital during the Environmental Surveillance Rounds dated from July 2017 until February 2018 were observed by the surveyors during the survey from 2/20 to 2/22/18. No action was taken by the hospital to address these issues when identified.

2. Areas in the ED observed in disrepair were not identified by the hospital on previous environmental or department rounds.

These failures created risks for patient care and safety.

Findings:

1. During a tour of the peri-operative area on 2/20/18 starting at 0931 hours, and of the ED on 2/21/18 at 0940 hours, multiple observations showed the areas were not maintained in a clean and sanitary manner and in good repair. Cross reference to A701, example #1.

Review of the OR Environmental Surveillance Rounds report performed by the peri-operative department showed the following:

* On 7/14/17, stains on the wall in ORs 3, 4, 5, 6, and 7.

* On 7/28/17, the paint was chipped on the door in OR 6. The scrub sink in the substerile room next to OR 7 was out of service, previously reported on 7/12/17.

* On 8/6/17, there were stains on the walls and/or ceilings in multiple areas throughout the department. All doors and door jams needed painting. The paint and/or veneer was peeling or chipped off.

* On 8/14/17, multiple areas of paint peeling off the walls were identified in every OR.

* On 9/15/17, scratches, cracks, and holes were identified in ORs 3, 4, 5, 6, and 7. Floor cracks were identified in ORs 3, 4, and 5.

* On 10/9/17, chipped walls were identified in OR 2 and chipped tiles were identified in OR 10. The inside of the door in OR 4 needed paint. The scrub sink in the sub-sterile room between OR 7 and OR 8 needed repairs that were previously reported on 7/2/17.

* On 10/16/17, there were scratches, cracks, and holes in ORs 3, 4, 5, 6, and 7 and floor cracks in ORs 3, 4, and 5. This was the same finding documented on 9/15/17.

* On 11/16/17, there were scratches, cracks, and holes identified in ORs 3, 4, 5, 6, and 7 and floor cracks were identified in ORs 3, 4, and 5. This same finding was documented on 9/15 and 10/16/17.

* On 11/30/17, ceiling tiles throughout the OR were identified to need paint or replacement.

* On 12/18/17 and January 2018, the findings were the same as 11/30/17.

* For February 2018, scratches, cracks, dents, and chips were identified in the main OR's, substerile rooms, and OR hallway.

During an interview with the QAPI committee on 2/22/18 at 1000 hours, the committee members were asked how the OR environmental rounds report, identifying the same findings from July 2017 until now, were reported. The Quality Medical Director stated the QAPI committee received the report, however, no action was taken.


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2. On 2/21/18 at 0940 hours, observation of the physical environment in the ED showed the observation areas were in need of repair. Cross reference to A701, example #2.

On 2/21/18 at 0940 hours, during an interview with the Director of Clinical Operations and Executive Director, the Director stated work orders should have been put in for the three areas in the ED observed in need of repair. During a follow-up interview with the Director at 1030 hours, the work orders were provided. The Director stated the work orders were not previously submitted as the areas in disrepair were not identified on previous environmental or department rounds.

Based on interview and medical record review, the hospital failed to ensure the physician followed the P&P for daily documentation of the continued necessity for the central catheters for three of 33 sampled patients (Patients 3, 30, and 32). This had the potential for the patients to not receive the appropriate care as the medical information was not accurate and complete.

Findings:

Review of the hospital's P&P titled Vascular Access Device, Adult: PICC last revised 10/16 showed in part: "I. D. Line necessity should be reviewed and confirmed with the physician daily."..."IV. B. 3. Make sure the order is entered, so that reminder for the daily assessment of line necessity shows on the Care Summary."

Review of the Medical Staff Bylaws approved 1/16 showed daily progress notes shall be entered on the chart of each patient and include reassessments, clinical observations, and response to care.

1. On 2/22/18 at 0900 hours, the medical record for Patient 3 was reviewed. The patient was admitted to the hospital on 2/12/18. Review of Patient 3's H&P dated 2/13/18, showed a TICC line was verified by x-ray. Review of the Medicine Progress Note dated 2/14, 2/15, 2/16, 2/17, 2/18, 2/20, and 2/21/18, showed a section titled LINES with a documented entry "N/A."

2. On 2/22/18 at 0930 hours, the medical record for Patient 30 was reviewed. The patient was admitted to the hospital on 2/2/18. Review of Patient 30's portable chest x-ray report dated 2/3/18 at 1345 hours, verified the central venous line placement. Review of the Medicine Progress Note dated 2/5/18, showed a section titled LINES with a documentation entry "N/A."

3. On 2/22/18 at 0915 hours, the medical record for Patient 32 was reviewed. The patient was admitted to the hospital on 2/17/18. Review of Patient 32's Medicine Progress Note dated 2/21/18, showed a PICC line was verified by x-ray. However, under the section titled LINES, the physician documented "N/A."

On 2/22/18 at 1000 hours, an interview and concurrent medical record review was conducted with the Director of Clinical Transformation and RN 6. The Director stated the physician was to choose from a drop down box on the Care Summary when drains or lines were present; "N/A" should not be chosen for a patient with an intravenous line.

Based on observation and interview, the hospital failed to ensure the peri-operative and ED areas were maintained in a clean, sanitary manner and were in good repair, creating the risk of unsafe care and injury to the patients, visitors, and staff.

Findings:

1. On 2/20/18 starting at 0931 hours, the peri-operative area was toured with the Executive Director Surgery.

a. During a tour of the pre-operative holding area, the following was observed:

* The hinges on the double doors leading into to the OR corridor were missing.

* A wipe warmer was on top of a metal cart. An accumulation of dust was noted on the top of the cart and inside the drawer.

b. During a tour of the pre-operative area, the following was observed:

* Paint was peeling off the surface of the door.

* The call light cover over the patient's bathroom was missing.

c. During a tour of the main OR and substerile rooms, the following was observed:

* A wood cabinet for the surgical attires at the entrance of the OR was missing the exterior finish, leaving the raw wood exposed underneath.

* The inside of the door of OR 6 was chipped and the paint was peeling.

* The paint on the walls in ORs 4 and 17 was peeling.

* The top and sides of a metal cabinet were corroded and rusty in the sub-sterile room between ORs 7 and 8.

* The top and sides of a metal cabinet were corroded and rusty in the sub-sterile room between ORs 3 and 4.

* In the Cysto room, the plastic corner guard of the wall was secured with tape, and the top and sides of a metal cabinet were corroded and rusty.

* A hole was observed on the ceiling next to the ceiling exhaust vent in the Cysto Supply room.

* The paint on the ceiling was peeled off in the Center Core room.

The Executive Director Surgery verified the above findings.

d. During a tour of the CVOR with the OR Clinical Manager on 2/21/18 starting at 1420 hours, the following was observed:

* In CVOR 1, a portion of the door material leading out to the sub-sterile room was missing, creating an uneven surface.

* In CVOR 2, the paint was peeled off the wall.

* In the Substerile room, the paint of the wall was chipped and the ceiling exhaust vent was rusty.

* In the CVOR 3, the paint was peeled off the wall behind the sink.

* Midway through the OR corridor, a cracked finish was noted on the ceiling.

The OR Clinical Manager verified the above findings.


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2. On 2/21/18 at 0940 hours, a tour of the ED was conducted with the Director of Clinical Operations and Executive Director. The following observations were made:

* EVS 3 was cleaning a sink in a treatment bay. While wiping with a cloth EVS 3 pushed the faucet arm which was loose and the faucet arm disconnected from the sink.

* A countertop in ED 3 had a broken edge with porous material exposed.

* A green substance was observed in the space where the backsplash had pulled away from the sink in ED 3.

The Director stated work orders should have been put in for the three areas observed in need of repair. During a follow-up interview with the Director at 1030 hours, the work orders were provided. The Director stated the work orders were not previously submitted as the areas in disrepair were not identified on previous environmental or department rounds.

Based on observation, interview, and record review, the hospital failed to ensure the temperatures in a blanket warmer in the OR were maintained at temperatures less than 130 degrees F as per the hospital's standard. This failure created the risk of unsafe care and injury to the patients.

Findings:

During the State Relicensing survey conducted from 1/8 to 1/11/18, the hospital was cited for the deficient practice of not ensuring the temperature in the blanket warmer did not exceed the acceptable temperature ranges as per the hospital's standards. The hospital's plan of correction to this survey dated 2/11/18, showed the hospital provided education to the staff on monitoring temperature ranges in the blanket warmers and appropriate actions were to be implemented when the temperature was outside the manufacturer's required range.

Review of the education material provided by the hospital showed the blanket warmers should be kept at a temperature of 130 degrees F or lower. The temperature needs to be logged daily on the blanket warmer temperature log. If the temperature of a blanket warmer was noted to be higher than 130 degrees F, the staff were to open the door to cool the chamber and check the setting, reducing it to 130 degrees if it is set higher.

On 2/20/18 starting at 1250 hours, a tour of the OR area was conducted with the Executive Director Surgery. The temperature of a blanket warmer in the OR area was 136 degrees F.

Review of the Daily Warmer Temperature Log showed the blanket warmer's acceptable temperature was 130 degrees F.

Review of the Daily Warmer Temperature Log for February 2018 showed the temperature of the blanket warmer ranged between 133 to 138 degrees F from 2/1 through 2/20/18, except on 2/17/18 (no documented temperature). Further review of the Temperature Log showed an area to document "Action Taken." However, there was no documentation to show any interventions when the temperatures exceeded 130 degree F for the above dates.

The Executive Director Surgery verified the temperatures for the blanket warmer were not within the hospital's standards.

Based on observation, interview, and record review, the hospital failed to ensure the IC officers developed an effective system to implement and evaluate measures for identification, investigation, reporting, and preventing infections within the hospital as evidenced by:

1. The hospital failed to provide evidence to demonstrate there was oversight of their contracted EVS department, to ensure a clean environment was maintained in the central sterile department and in the SPD.

2. The hospital failed to ensure all flexible scopes were high level disinfected according to the nationally recognized infection control standards.

3. Failure to ensure the OR staff completely cleaned an OR prior to preparing the OR table for the next surgical case.

4. The hospital failed to ensure the perioperative environment was maintained in a clean, sanitary manner as per the AORN's guidelines.

5. Failure of the EVS staff to maintain correct cleaning procedures according to the hospital's standards and the manufacturer's instructions for the use of OxyCide.

6. Failure of the RNs to verbalize the correct wet times for the use of Sani-Cloth Bleach Wipes on glucometers, and failed to ensure the P&P provided guidance on the use of Sani-Cloth Bleach wipes for glucometers.

7. Failure to maintain the 7 East nourishment room in a sanitary condition.

8. Corrugated cardboard boxes containing clean supplies were observed in the 5 West supply room and 4 South supply room. Plastic bins containing clean supplies in the 4 South supply room were not maintained in a clean and sanitary manner.

These failures increased the risk of the spread of infections to the patients, staff, and visitors in the hospital.

Findings:

1. The AORN, one of the nationally recognized infection control guidelines the hospital followed, defines terminal cleaning as "thorough environmental cleaning that is performed at the end of each day when the area is being used." Both the AORN and AAMI (Association for the Advancement of Medical Instrumentation) ST79 recommend that sterile processing be terminally cleaned the same as the operating, delivery, and invasive procedure rooms. The AAMI ST79 (Section 3.4) states that the best practice is to provide separate housekeeping facilities for the decontamination and clean areas to avoid transferring contaminates from "dirty to clean" areas.

The AORN further stipulates, "Scheduled cleaning is a cleaning schedule that defines areas and equipment that should be cleaned on a regular (e.g., weekly, monthly) basis."

The AORN recommends terminal cleaning and disinfection of the sterile processing¿areas "be performed daily when the areas are¿being used." Terminal cleaning should not be¿performed when personnel are actively de-contaminating instruments. Cleaning should progress from cleanest to dirtiest areas.

The AORN recommends (Recommendation V) a schedule for cleaning the following: "Clean and soiled storage areas, storage cabinets, sterile storage area, aerators on faucets should be cleaned and disinfected on a routine basis ..."

During multiple observations on 2/20/18 commencing at 0945 hours, of the hospital's Central Sterile and Sterile Processing Departments, the floors throughout the departments contained large amounts of black matter.

During a concurrent interview with the SPM, he was asked to wipe a large area of the floor, full of black matter, which was adjacent to an instrument washer. A wet wipe used to wipe the floor was full of black matter and the SPM stated it looked like dirt. He was asked if there was oversight from the facility to ensure EVS was performing thorough cleaning of the departments. He stated there was no oversight at the present time.

At 1000 hours, the EVS Director, employed by the hospital's contracted service, was asked about the black matter throughout the Central Sterile Department that was easily removed with a wet wipe. The Director stated, "It could use some improvement." In addition, he stated other than himself, no one from the hospital provided oversight of the EVS staff.

An interview was conducted with EVS Lead 1 on 2/20/18 at 1100 hours, following the observation of the SPD. The EVS Lead stated no EVS staff were specifically assigned to clean the SPD or Central Sterile Departments, it was one of her tasks to clean the areas but she also had the responsibility of cleaning the physician's sleeping quarters and the men's bathroom. The EVS Lead also stated the assignment was a lot of work; when the SPD needed cleaning someone from SPD notified the EVS department.

During a follow-up interview with the Director of EVS on 2/20/18 at 1115 hours, he stated, "I will look into ensuring the night shift staff are terminally cleaning, they do the best they can."

2. On 2/20/18 at 1300 hours, the hospital's endoscopy processing decontamination room (a workspace room used to process and clean equipment/instruments which contain contaminants such as micro-organisms or hazardous materials, including chemicals, radioactive substances, and infectious disease) of scopes was observed accompanied by the Director of Regulatory Affairs. Upon entering the room, two (2) channel port tubings, used for cleaning scopes, were observed hanging from a water filled hopper (a sink shaped device used similar as a toilet and used for disposing waste). The end of the tubings were observed submerged beneath the water level of the hopper.

During a concurrent interview with GI Technician 1 (GIT 1) he stated the tubings were hung from the hopper to drain the water from the tubings. GIT 1 stated they also submerged/soaked the brushes used for cleaning the scopes in the hopper and used the brushes to pre-clean the scopes.

Following the observation of the scope cleaning process, the Director of Regulatory Affairs instructed the staff to immediately cease the observed practice, and reprocess all scopes and to cover the hopper. The Director informed GIT 1 the hopper was in sense, a toilet and was not to be used to clean the scopes.

On 2/20/18 at 1500 hours, interview with ICP 1 was conducted. When asked if she was aware the GI technicians were using the hopper to pre-clean the scopes, ICP 1 stated she was not aware of the practice and ensure the practice was immediately stopped and all the scopes were reprocessed.


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3. On 2/20/18 at 1346 hours, the OR staff cleaning an OR between surgical cases was observed with RN 7.

* At 1346 hours, the OR staff began cleaning OR 6.
* At 1350 hours, the OR table was cleaned.
* At 1357 hours, a clean cover was placed on the OR table for the next case.
* At 1359 hours, the OR staff began cleaning the soiled floor.

On 2/21/18 at 1029 hours, RN 7 verified the OR staff prepared for the next case before the OR was completely cleaned.

4. During an interview with the Executive Director Surgery on 2/20/18 at 0931 hours, the Director stated the hospital followed the AORN's guidelines as the hospital's standards of practice.

According to the AORN's Guidelines for Perioperative Practice, 2017 edition, Guidelines for Environmental Cleaning, the patient should be provided with a clean, safe environment. All horizontal surfaces (e.g., sterilizers, countertops, furniture, shelving) should be damp dusted daily with an EPA-registered disinfectant and a clean, low-linting cloth. Absorbent or non-intact surfaces may become reservoirs for microorganisms and may harbor pathogens. The integrity of structural surfaces (e.g. doors, floors, walls, ceilings, cabinets) should be maintained and surfaces should be repaired when damaged. Damaged surfaces can lead to an inability to clean and could create a fall or other injury hazard. Damaged structural surfaces may create a reservoir for the collection of dirt and debris that cannot be removed during cleaning.

During a tour of the peri-operative area on 2/20/18 starting at 0931 hours, multiple observations showed the areas were not maintained in a clean and sanitary manner and in good repair. Cross reference to A701 example #1.


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5. Review of the hospital's document regarding room cleaning titled Method of the Week: 7 Step Cleaning Process (undated), showed a room would be cleaned in the following order:

* Pull the trash and linen.
* High dust everything above shoulder level.
* Damp wipe all surfaces using a germicidal wipe
* Clean the bathroom and do not use the cleaning wipe on any other surface after cleaning the toilet. Start at the door and end with the toilet.
* Dust mop the floor.
* Damp mop the floor; moving from the far corner of the room to the entrance.
* Inspect the room.

When requested for the instructions-for-use of OxyCide, the hospital provided a document titled Memorial Care Long Beach Medical Center Environmental Services Hospital Approved Disinfectant Usage Procedure (undated). Review of the document showed OxyCide was a primary disinfectant used on all wipeable surfaces. The wet time for the product was five minutes to ensure proper disinfection.

a. On 2/20/18 at 1009 hours, EVS 1 was observed cleaning the restroom of a patient's room on the 6 South unit. The sink and mirror were in one area of the restroom and the toilet and shower stall were in a separate anteroom of the restroom, separated by a door.

EVS 1 pulled a green rag from the bucket labeled OxyCide without first removing the trash in the trash receptacle. EVS 1 wrung the towel in the bucket and used the rag to wipe down the sink. EVS 1 turned on the faucet and rinsed the green rag in the water and wrung it out. EVS 1 then proceeded to wipe down the counter with the same rag.

Without getting a new rag, EVS 1 rinsed the same rag in the restroom sink again and wrung it out. EVS 1 proceeded to wipe down the counter wall and restroom light switch with the rag.

EVS 1 then poured a neutral cleaner (non-disinfectant detergent) into the toilet bowl and used a toilet brush to scrub the inside of the bowl. Then EVS 1 used the brush to scrub the outer part of the toilet rim. EVS 1 retrieved a new green rag from the OxyCide bucket and wiped down the outside of the toilet. The same rag was then used to wipe down the adjacent walls on either side and behind the toilet.

Without changing gloves, EVS 1 used another cleaning solution to wipe down the shower stall and shower chair.

Without dust mopping first, EVS 1 mopped the bathroom floor starting at the floor area around the toilet, then moving to the shower stall. EVS 1 then mopped the area near the counter and sink. After mopping, EVS 1 picked up paper pieces from the floor using a brush and dustpan.

During an interview immediately following the observation, EVS 1 was asked to state the sequence of cleaning procedures. EVS 1 stated she was always scanning her unit to clean up necessary messes. However, she stated she normally kept to a schedule of emptying all the patient room trash receptacles first. EVS 1 stated then she mopped all the patient rooms and then cleaned the patient rooms.

b. Review of the hospital's P&P titled Nourishment Room Cleaning dated 1/18 showed the FNS will clean the refrigerators and beverage machines using a food grade germicidal solution. While damp wiping surfaces do not come into contact with any surface that comes into contact with food, ice, or beverages. Ice and beverage machine cleaning is limited to external wiping only.

Review of the hospital's instructions for use of OxyCide (undated) showed OxyCide is a primary disinfectant used on all wipeable surfaces. OxyCide is not to be used on any surfaces that come in contact with food, ice, or beverages. OxyCide is not used to clean the inside of the refrigerators.

On 2/20/18 at 1050 hours, an interview with EVS 2 was conducted concerning the cleaning of the 7 South unit's nourishment room. EVS 2 stated the refrigerator cleaning included removing the refrigerator shelving and wiping the inside with an OxyCide rag. EVS 2 stated she would wipe the exterior of the ice machine and the drain pan with OxyCide.

On 2/21/18 at 1333 hours, an interview was conducted with the Director of EVS and Director of Epidemiology and Employee Health Services. When informed of the above observations of the incorrect cleaning sequence and procedures for the cleaning of patient rooms and the nourishment room, the Director of EVS confirmed the EVS staff did not perform the cleaning procedures correctly. The Director stated the EVS staff should not dilute OxyCide or water it down with water. The Director confirmed the EVS staff was to follow the seven step process when cleaning the patient rooms, nourishment rooms, and restrooms. The Director of Epidemiology and Employee Health Services added the FNS was responsible for cleaning the refrigerators and not the EVS staff. The FNS used a food grade germicidal solution when cleaning food surface areas in the nourishment room. The Director of EVS stated OxyCide was not to be used on any surfaces that would come in contact with food.

c. On 2/21/18 at 0940 hours, a tour of the ED was conducted with the Director of Clinical Ops and Executive Director. An observation was made of EVS 3 cleaning a treatment bay. During a concurrent interview EVS 3 stated the patient was discharged and she was cleaning the bay for the next patient. EVS 3 was observed using a wet cloth from a bucket that contained the hospital approved disinfectant cleaner OxyCide. EVS 3 demonstrated there were 15 wet cloths in the bucket.

EVS 3 used one wet cloth to clean the sink, monitors, gurney, side rails, light switches, and door handle. The surfaces were observed to dry in three minutes. When asked if it was necessary to keep the surface wet for a certain number of minutes, EVS 3 stated "maybe five minutes, but it's okay if it dries before that." When asked why only one cloth was used for multiple pieces of patient care equipment, EVS 3 stated "I only need one, it's still wet."

The Director of Clinical Ops verified the above finding.

d. The 5 South unit was toured with the Director Clinical Ops - 5th Floor and Clinical Educator 1. During the tour EVS 5 was observed cleaning a patient room using the OxyCide disinfectant. During a concurrent interview, EVS 5 was asked to state the wet time for the OxyCide. At first EVS 5 stated 20 seconds, then stated no, the wet time for OxyCide was 10 minutes.

On 2/21/18 at 1315 hours, the Director of Epidemiology and Employee Health Services was informed a member of the EVS staff working on the medical unit did not know the correct wet time for the OxyCide disinfectant. The Director stated the EVS staff were recently retrained on the disinfectant wet times. When asked if the Infection Control Department was responsible for retraining the EVS staff, the Director stated the Infection Control professionals were involved in developing the educational materials; however, they did not provide the education to the EVS staff and the EVS management staff did the retraining.

6. According to the CDC's recommendations, Infection Prevention during Blood Glucose Monitoring and Insulin Administration updated 6/8/17, glucometers should not be shared whenever possible. If they must be shared, the device should be cleaned and disinfected after each use per the manufacturer's instructions. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared.

Review of the Instructions for Use Manual for Nova Statstrip (a type of glucometer), showed to clean and disinfect after each patient use by following this protocol to help ensure effective cleaning and disinfection. Cleaning is not the same as disinfecting. Disinfecting means to kill or prevent the growth of disease carrying microorganisms.

Review of the preventative and maintenance and troubleshooting section of the hospital's P&P titled Point-of-Care Blood Glucose Monitoring: Nova Statstrip Hospital Blood Glucose Monitoring System effective 2/1/18, showed proper disinfection of the meter included cleaning the meter prior to disinfecting it. When disinfecting the meter, a new Super Sani-Cloth wipe is used to thoroughly wipe all the surfaces of the meter. The wet time of two minutes is observed. However, there was no direction in the P&P to show the wet time for the use of bleach wipes when used for patients with clostridium difficil (a type of bacterial infection), which required contact precautions.

Review of the manufacturer's guidelines for the Sani-Cloth Bleach wipes showed the disinfected area should remain wet for four minutes for complete disinfection.

* On 2/10/18 at 1030 hours, RN 2 was interviewed. When asked to explain the cleaning procedures for the glucometers when used for patients with C. difficil infections, RN 2 stated she would use the Sani-Cloth Bleach wipes and ensure the glucometer remained wet for two minutes.

* On 2/20/18 at 1048 hours, RN 3 was interviewed. RN 3 was asked to explain the process for cleaning the glucometers. The RN stated the Sani-Cloth Bleach wipes were used to wipe down the glucometer if it was used on a patient infected with C. difficil. When asked for the wet time, RN 3 stated three minutes.

On 2/21/18 at 1333 hours, the Director Epidemiology and Employee Health Services was interviewed. The Director verified the retraining material for the disinfection of glucometers did not include the use of Sani-Cloth Bleach Wipes for the nursing staff. In addition, the Director verified the P&P did not include guidance for the use of the Sani-Cloth Bleach Wipes to disinfect the glucometers when used with patients infected with C. difficil.

7. On 2/20/18 at 1036 hours, a tour of the nourishment room on 7 East was conducted with the Director Clinical Ops - ICU/CCU and CNO. The floor of a storage cabinet used to store crackers, straws, and sugar packets was observed with a thick layer of dust and small particles.

The Director acknowledged the finding and stated the cabinet should be cleaned immediately.


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8. On 2/20/18 at 1316 hours, the 5 West unit was toured with the Director of Clinical Ops - 5th floor and Clinical Educator 1. Two corrugated cardboard boxes containing clean lab specimen bags were observed in the clean supply room. The Director stated the lab specimen bags should not be stored in a container from the outside; they should be removed from the boxes and stored in plastic bins.

On 2/20/18 at 1340 hours, the 4 South unit was toured with the Director Clinical Ops - Ortho/Neuro. One corrugated cardboard box containing clean plastic bags and one corrugated cardboard box containing isolation bags were observed in the clean supply room. The Director immediately removed the supplies and confirmed the supplies should not be stored in cardboard boxes anywhere on the unit.

Inspection of the plastic supply bins in the clean supply room showed multiple bins were stocked with clean supplies. Trash, debris, and heavy dust build up was observed inside and along the outside edges of the bins. The Director verified the findings. When asked who was responsible for cleaning the bins, the Director stated the Central Supply Department stocked the bins and were responsible for their maintenance.

Based on observation, interview, and record review, the CEO, medical staff, and CNO failed to provide oversight to ensure active surveillance of the hospital-wide EVS and their EVS contracted services. In addition, they failed to ensure their hospital wide QAPI program was actively involved in safeguarding a comprehensive, hospital wide infection control program. These failures created the risk of not addressing the infection prevention needs and the increased the risk of spreading infections.

Findings:

On 2/22/18 at 1000 hours, a formal QAPI meeting was conducted with the survey team and the hospital's QAPI committee and senior leadership. The survey team shared the deficient practices identified during the survey, specific to the lack of cleanliness of the environment (which were also identified during the State Relicensing Survey conducted on 1/8 - 1/11/18). The CNO was asked if the senior leadership ensured their QAPI and Infection Control Program conducted active surveillance to safeguard the cleanliness of the hospital wide environment.

During an immediate interview, the CNO stated she waited for the ICP to report any concerns to her. The CNO stated currently no active surveillance was performed by her or the QAPI program. The CNO also stated they would be working to ensure the hospital provided direct oversight of their EVS contracted services. The CNO stated she was made aware there was no direct oversight of the Director of EVS (contracted staff) and stated they would be changing that practice.

No documents were provided during the survey to show there was active surveillance or oversight of the EVS contracted services.