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Based on observation, interview and record review it was determined the Condition of Participation: Physical Environment was not met. The facility failed to maintain the physical environment to ensure the safety and well-being of patients.

A Life Safety Code survey was conducted on 03/12/13. Life Safety Code deficiencies were cited that determined the Condition for Participation for Physical Environment at 42 CFR 482.41 was not met under A710.

Refer to LSC tags: were K29, K31, K62, K64, and K69.

Based on observation, interview and record review, it was determined the facility failed to maintain the physical environment to ensure the safety and well-being of patients.

A Life Safety Code survey was conducted on 03/12/13. Life Safety Code deficiencies were cited at 42 CFR 482.11.

Refer to LSC tags: K29, K31, K62, K64, and K69.

Based on observation, interview, and review of the facility's policy and procedure, it was determined the facility failed to ensure their system for controlling infections was followed regarding the aseptic technique practices of the storage of sterilized surgical instruments in the Emergency Department supply area.

The findings include:

A review of the facility's policy/procedure titled, "Event Related Sterility Assurance", IC.01.01.01, last revised January 2013, revealed sterilized items must be maintained in a controlled storage environment. The controlled storage environment was defined as having a limited possibility of microbial contamination, low level of traffic, maintained temperature, humidity and air movement. The Sterile Supply storage room and the Central Sterile Processing area were identified as meeting these environmental conditions. Procedure item #1 stated sterilized items wrapped in muslin shall be placed in dust covers (items which will not be used very often). Further review of Procedure #3 revealed rotation of supplies is important to ensure previously processed items were used first and the task should be done by the Operating Room (OR) staff.

An observation of the Emergency Department supply room, on 03/11/13 at 3:30 PM, revealed a tray of surgical instruments wrapped in green muslin was on the supply cart in the bin containing intravenous tubing. The surgical instruments wrapped in muslin did not have a dust cover. The muslin was secured with sterilization tape indicating the package had been sterilized and the date tag was marked July 20, 2012 as the date of sterilization. The sterilized tray was positioned at the front of the bin and prevented staff access to the intravenous tubing without handling the muslin wrapped tray.

Further observation of the Emergency Department supply room, on 03/13/13 at 8:14 AM, revealed the tray of surgical instruments wrapped in green muslin without a dust cover was still in the same bin with the intravenous tubing supplies. In addition, there were five trays marked obstetrical (OB) delivery tray that were wrapped in green muslin without a dust cover and stored on a corner shelf. The top OB tray had sterilization tape that was broken and the muslin wrapping was not secured with the sterilization date as 04/30/12. The sterilization tape and green muslin was intact on the remaining OB trays with no obvious soiling of the muslin fabric and the sterilization dates were marked as 07/20/12, 07/23/12, 07/27/12, and 08/06/12.

Interview with Registered Nurse (RN) #1, on 03/13/13 at 8:22 AM, revealed the OB trays were kept in the supply room for emergency deliveries since the hospital no longer had an obstetrical unit anymore. RN #1 was not aware of a time the trays had been needed. RN #1 revealed the tray with sterile instruments was not needed because they used prepackaged trays for all procedures in the emergency room. RN #1 did not know how long the sterilized trays had been in the supply area.

Interview with the Emergency Department Director, on 03/13/13 at 8:50 AM, revealed the facility's policy/procedure directed that the infrequently used sterilized items stored in the Emergency Department Supply areas must have dust covers to ensure sterility.