HospitalInspections.org

Based on random observation, label review, and interview, the provider failed to maintain the following items/areas in good/useable/cleanable/durable condition to provide for the overall safety and well-being of patients:
* Three of three countertops in the clean processing side of central sterilization.
* The north wall of the clean supply room at the Lombardy site.
* The wall around the west exit door and the mop board of the clean supply room at the Lombardy site.
* Two of two changing tables in the women's restroom at the imaging site used improper disinfectant between use.
* One of two changing table mats in the women's restroom at the imaging site was torn and ripped.
* Two of three pairs of spinal positioning frames in a utility room between operating room (OR) 1 and OR 2 had torn and cracked vinyl.
* The vitrectomy positioning board in OR 6 had bare wood exposed.
* The OR area had a bumper board in the corridor with a large hole.
Findings include:

1. Observation at 2:15 p.m. on 6/14/11 revealed two countertops in the clean processing side of central sterilization had chipped laminate exposing the raw wood (photos 8 and 9). The other countertop on the rolling table had deep scratches and gouges that harbored debris and were not cleanable. Interview with the director of purchasing and project development at the time of the observation confirmed those findings. He stated he was not aware those countertops were in need of repair or replacement.

2. Observation at 2:20 p.m. on 6/14/11 revealed the wall on the north side of the clean supply room for the processed instruments outside of central sterilization had several grooves, gouges, and holes in the gypsum board wall that exposed the chalk beneath the surface paper (photos 6 and 7). Interview with the director of purchasing and project development at the time of the observation confirmed those findings. He stated he was aware of the condition of the wall. He stated they had purchased new rolling storage carts, and those carts had damaged the wall.

3. Observation at 2:25 p.m. on 6/14/11 revealed the wall, approximately one foot wide, around the west exit door of the clean supply room for the processed instruments outside of central sterilization had unfinished gypsum board (photo 5). Approximately one foot of the mop board under the unfinished gypsum board was torn away from the wall (photo 10).
Interview with the director of purchasing and project development at the time of the observation confirmed those findings. He stated they had to remove the door to bring in a new boiler a few weeks ago and had not refinished the wall or repaired the mop board around the door.

4. Observation at 1:30 p.m. on 6/15/11 revealed a diaper changing table in the women's restroom at the imaging site. Interview with the director of guest services (DGS) at the time of the observation revealed the provider kept a spray bottle of disinfectant to clean and disinfect the diaper changing mat and table after use by the patients or guests. He stated that table and another had been installed in the women's restroom at the main site about a year ago. Review of the label for the disinfectant revealed no guidelines for use on direct skin contact surfaces. There were no distinct directions for use on changing tables and/or mats. Interview with the DGS at the time of the observation revealed he was not aware that particular disinfectant could not be used on diaper changing mats. Further interview with the DGS revealed the spray bottle was kept underneath the unlocked changing tables for patron use.

5. Observation at 1:30 p.m. on 6/15/11 revealed a diaper changing table in the women's restroom at the imaging site. Closer observation revealed a rip and tear in the vinyl covering of the diaper changing mat on top of the table. The rip and tear was the size of a large V, was approximately two inches long on each side, and exposed the batting beneath the vinyl. Interview with the DGS at the time of the observation confirmed that finding. He stated he was not aware that mat had a rip in it and would have it replaced.



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6. Observation on 6/15/11 from 1:15 p.m. through 2:30 p.m. revealed:
*In a utility room between operating room (OR) 1 and OR 2 two of three pairs of spinal positioning frames had torn and cracked vinyl that exposed the foam padding (photos 2, 3, and 4 ).
*In OR 6 a vitrectomy positioning board had bare wood exposed on the top and all edges.
*In the OR corridor an area of bumper board had a hole approximately 6 inches by 3 inches (photo 1).

Interview on 6/15/11 at 2:30 p.m. with the OR nurse manager confirmed:*The spinal positioning frames vinyl frames had exposed foam and rough edges.
*Any pads or positioning frames that had cracks or tears were to be taken out of use until repaired.
*He was not aware of the hole in the bumper board in the OR corridor.

Based on observation, interview, and policy review, the provider failed to ensure proper handwashing and glove use were used during one of one drain removal for one of one patient (12). Findings include:

1. Observation on 6/14/11 from 11:35 a.m. through 11:50 a.m. revealed registered nurse (RN) A:
*Used an alcohol foam on her hands.
*Placed two packages of 4 inch by 4 inch gauze, tape, two red biohazard bags, and a pair of gloves on patient 12's bed.
*Removed the bedding covering patient 12's right leg.
*Retrieved and placed a disposable barrier cloth on the bed next to patient 12's right leg.
*Placed the gloves and gauze on the barrier cloth.
*Put on the gloves.
*Handled the drain collection tubing and reservoir.
*Removed a dressing from patient 12's right thigh and upper hip.
*Removed the drain tubing from patient 12's right thigh.
*Opened the packages of gauze, folded them in half, and placed them over the drain site and incision site.
*Taped the gauze in place.
*Placed the soiled dressing, drain tubing, and drain reservoir in a red biohazard bag.
*Carried the red biohazard bag into the bathroom.
*Emptied and measured the drain reservoir of blood, and then disposed of the blood in the toilet.
*Removed her gloves and placed them in the red biohazard bag with the soiled dressing and drain.
*Closed the red biohazard bag.
*Washed her hands for approximately five seconds and shut the faucet off with her wet hands.
*Rearranged patient 12's urinary catheter tubing.
*Assisted patient 12 to move up in the bed.
*Removed the cover from patient 12's lunch tray and pushed the overbed table closer to the patient.
*Washed her hands for approximately five seconds and shut the faucet off with her wet hands.

Interview on that same date at 11:50 a.m. with RN A confirmed:*She should have changed her gloves and either washed her hands or used the alcohol foam before she had applied the clean dressing.
*She had not washed hands using the correct procedure.

Interview on 6/15/11 at 9:00 a.m. with the infection control nurse revealed:*Glove use and handwashing were included in the yearly infection control in-service.
*She agreed the correct procedure had not been used by RN A.

Review of the provider's revised 4/13/10 handwashing policy revealed:
*Decontamination (by use of handwashing or an alcohol based hand rub) of hands should be completed before and after:
-Having direct contact with patients.
-Wound dressing changes.
-Moving from a contaminated body site to a clean body site during patient care.
*Hand hygiene technique included:
-Washing hands with soap and water for at least 15 seconds.
-Dry hands thoroughly.
-Use a towel to turn off the faucet.
*Gloves were to be changed during patient care when moving from a contaminated body site to a clean body site.

Based on random observation, label review, and interview, the provider failed to maintain the following items/areas in good/useable/cleanable/durable condition to provide for the overall safety and well-being of patients:
* Three of three countertops in the clean processing side of central sterilization.
* The north wall of the clean supply room at the Lombardy site.
* The wall around the west exit door and the mop board of the clean supply room at the Lombardy site.
* Two of two changing tables in the women's restroom at the imaging site used improper disinfectant between use.
* One of two changing table mats in the women's restroom at the imaging site was torn and ripped.
* Two of three pairs of spinal positioning frames in a utility room between operating room (OR) 1 and OR 2 had torn and cracked vinyl.
* The vitrectomy positioning board in OR 6 had bare wood exposed.
* The OR area had a bumper board in the corridor with a large hole.
Findings include:

1. Observation at 2:15 p.m. on 6/14/11 revealed two countertops in the clean processing side of central sterilization had chipped laminate exposing the raw wood (photos 8 and 9). The other countertop on the rolling table had deep scratches and gouges that harbored debris and were not cleanable. Interview with the director of purchasing and project development at the time of the observation confirmed those findings. He stated he was not aware those countertops were in need of repair or replacement.

2. Observation at 2:20 p.m. on 6/14/11 revealed the wall on the north side of the clean supply room for the processed instruments outside of central sterilization had several grooves, gouges, and holes in the gypsum board wall that exposed the chalk beneath the surface paper (photos 6 and 7). Interview with the director of purchasing and project development at the time of the observation confirmed those findings. He stated he was aware of the condition of the wall. He stated they had purchased new rolling storage carts, and those carts had damaged the wall.

3. Observation at 2:25 p.m. on 6/14/11 revealed the wall, approximately one foot wide, around the west exit door of the clean supply room for the processed instruments outside of central sterilization had unfinished gypsum board (photo 5). Approximately one foot of the mop board under the unfinished gypsum board was torn away from the wall (photo 10).
Interview with the director of purchasing and project development at the time of the observation confirmed those findings. He stated they had to remove the door to bring in a new boiler a few weeks ago and had not refinished the wall or repaired the mop board around the door.

4. Observation at 1:30 p.m. on 6/15/11 revealed a diaper changing table in the women's restroom at the imaging site. Interview with the director of guest services (DGS) at the time of the observation revealed the provider kept a spray bottle of disinfectant to clean and disinfect the diaper changing mat and table after use by the patients or guests. He stated that table and another had been installed in the women's restroom at the main site about a year ago. Review of the label for the disinfectant revealed no guidelines for use on direct skin contact surfaces. There were no distinct directions for use on changing tables and/or mats. Interview with the DGS at the time of the observation revealed he was not aware that particular disinfectant could not be used on diaper changing mats. Further interview with the DGS revealed the spray bottle was kept underneath the unlocked changing tables for patron use.

5. Observation at 1:30 p.m. on 6/15/11 revealed a diaper changing table in the women's restroom at the imaging site. Closer observation revealed a rip and tear in the vinyl covering of the diaper changing mat on top of the table. The rip and tear was the size of a large V, was approximately two inches long on each side, and exposed the batting beneath the vinyl. Interview with the DGS at the time of the observation confirmed that finding. He stated he was not aware that mat had a rip in it and would have it replaced.



26632

6. Observation on 6/15/11 from 1:15 p.m. through 2:30 p.m. revealed:
*In a utility room between operating room (OR) 1 and OR 2 two of three pairs of spinal positioning frames had torn and cracked vinyl that exposed the foam padding (photos 2, 3, and 4 ).
*In OR 6 a vitrectomy positioning board had bare wood exposed on the top and all edges.
*In the OR corridor an area of bumper board had a hole approximately 6 inches by 3 inches (photo 1).

Interview on 6/15/11 at 2:30 p.m. with the OR nurse manager confirmed:*The spinal positioning frames vinyl frames had exposed foam and rough edges.
*Any pads or positioning frames that had cracks or tears were to be taken out of use until repaired.
*He was not aware of the hole in the bumper board in the OR corridor.

Based on observation, interview, and policy review, the provider failed to ensure proper handwashing and glove use were used during one of one drain removal for one of one patient (12). Findings include:

1. Observation on 6/14/11 from 11:35 a.m. through 11:50 a.m. revealed registered nurse (RN) A:
*Used an alcohol foam on her hands.
*Placed two packages of 4 inch by 4 inch gauze, tape, two red biohazard bags, and a pair of gloves on patient 12's bed.
*Removed the bedding covering patient 12's right leg.
*Retrieved and placed a disposable barrier cloth on the bed next to patient 12's right leg.
*Placed the gloves and gauze on the barrier cloth.
*Put on the gloves.
*Handled the drain collection tubing and reservoir.
*Removed a dressing from patient 12's right thigh and upper hip.
*Removed the drain tubing from patient 12's right thigh.
*Opened the packages of gauze, folded them in half, and placed them over the drain site and incision site.
*Taped the gauze in place.
*Placed the soiled dressing, drain tubing, and drain reservoir in a red biohazard bag.
*Carried the red biohazard bag into the bathroom.
*Emptied and measured the drain reservoir of blood, and then disposed of the blood in the toilet.
*Removed her gloves and placed them in the red biohazard bag with the soiled dressing and drain.
*Closed the red biohazard bag.
*Washed her hands for approximately five seconds and shut the faucet off with her wet hands.
*Rearranged patient 12's urinary catheter tubing.
*Assisted patient 12 to move up in the bed.
*Removed the cover from patient 12's lunch tray and pushed the overbed table closer to the patient.
*Washed her hands for approximately five seconds and shut the faucet off with her wet hands.

Interview on that same date at 11:50 a.m. with RN A confirmed:*She should have changed her gloves and either washed her hands or used the alcohol foam before she had applied the clean dressing.
*She had not washed hands using the correct procedure.

Interview on 6/15/11 at 9:00 a.m. with the infection control nurse revealed:*Glove use and handwashing were included in the yearly infection control in-service.
*She agreed the correct procedure had not been used by RN A.

Review of the provider's revised 4/13/10 handwashing policy revealed:
*Decontamination (by use of handwashing or an alcohol based hand rub) of hands should be completed before and after:
-Having direct contact with patients.
-Wound dressing changes.
-Moving from a contaminated body site to a clean body site during patient care.
*Hand hygiene technique included:
-Washing hands with soap and water for at least 15 seconds.
-Dry hands thoroughly.
-Use a towel to turn off the faucet.
*Gloves were to be changed during patient care when moving from a contaminated body site to a clean body site.