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Based on observation, interview, and record review, the facility failed to wear personal protective equipment while disposing of biological materials in 1 of 1 observations resulting in the potential for transmission of infectious agents to all surgical patients served by the facility. Findings include:

On 1/30/2017 at 1100, Staff M was observed in a Biohazard/Decontamination room emptying a suction canister, that was approximately half full with grossly bloody fluid, into a hopper without wearing a face shield and or goggles. Staff M was queried on 1/30/2017 at 1100 as to where his face shield was to which he replied, "It's up there" pointing to a shelf to his left. After disposing of the canister and performing hand hygiene, Staff M applied a face shield and wrapped a glove around two fingers before flushing the hopper. He then disposed of the glove and removed the face shield and disposed of it. These observations were confirmed by Staff X and Staff AH on 1/30/2017 at 1100. On 1/30/2017 at 1103, Staff X stated to Staff M, "You should be wearing a face shield to protect yourself."

Facility policy 2 IC 033 "Infection Control in the Environment of Care" was reviewed on 1/31/2017 at 1627. Policy states, "All human blood, blood products and body fluids shall be flushed in the hopper or the toilet utilizing appropriate personal protective equipment and taking care not to splash fluids in the face."

Additionally, policy 2 IC 008 "MIOSHA Bloodborne Pathogens Exposure Control Plan" was reviewed on 1/31/2017 at 1635. Policy states, "Body fluids will be flushed down the sewer system using hoppers or the toilet, during which the employee will wear the appropriate PPE (personal protective equipment)."

Based on record review, observation, interview, the facility failed to provide 1) sufficient surgical instrumentation during busy time periods and 2) sufficient staff to complete timely cleaning of surgical instrumentation resulting in the potential for poor surgical outcomes including risk of infection. Findings include:

1) On 1/31/2017 at 0830, flash sterilization logs were reviewed for October 2016-present and it was noted that there was a higher flash rate on Mondays and Thursdays. On 1/31/2017 at 0856, Staff L was queried as to why the flash rates were higher on those days than other days of the week to which she replied "Monday is a very busy day for surgery and we need more instruments." She stated that they "find more holes in the wraps" on Monday's than any other day because "the instrumentation tends to be heavier that day." Staff L additionally stated "Thursday is a big plastics day for us. Recently we did a full inventory of all of the instruments and we have identified several sets that were always missing pieces. We are getting three more full hand (surgery) sets."

In an interview with Staff K on 1/31/2017 at 1450, he stated that a full inventory of all surgical instruments for the entire "central campus" was done and showed major variances between the amount of surgical instruments actually on hand versus the number that the computer system indicated was on hand. Staff K further stated, "We were shocked at the disparity between the book inventory and the physical inventory."

2) During observations made on 1/30/2017 at 1140, case cart #17 was followed from surgery to the central sterile processing department (CSP). Five personnel were observed working. The area appeared disorganized and cluttered with stacks of instruments everywhere and had no easily identifiable way to discern where the instruments were in the decontamination process. Six case carts were present with doors opened revealing used instrumentation stacked inside. Additionally, multiple stacked sets of used instruments, waiting to be hand washed, were sitting on a table between the case carts and the sinks. On 1/30/2017 at 1143 Staff K stated that it would be at least two hours before case cart #17 would have the instruments removed and it might take longer than that for the instruments to begin the decontamination process. Staff K was queried as to what length of time it should take to start the decontamination process of the instruments once they arrive in CSP to which he replied that they "get to them as soon as (they) can." Staff K was then queried as to staffing levels for the CSP to which he replied that he employs 89 staff in the department and that 24 are scheduled to work the day shift between the decontamination side and the clean/assembly/sterilization side. Staff K further stated that he was "short 13 people today" because of call-ins and vacations. Staff K said, "I supplement with overtime which happens extremely frequently." At 1426 on 1/30/2017, CSP decontamination was re-entered and case cart #17 was observed sitting in the same place (2 hours and 46 minutes later) with the doors opened and the used instruments still inside.

The clean side of CSP was entered on 1/30/2017 at 1510. Ten staff members including supervisors were seen working in the course of their jobs. Multiple stacks of clean instruments were observed sitting around all of the approximately 8 work stations within the department waiting to be assembled into trays and sterilized for surgical use. The area appeared to be very cluttered and disorganized. 3 staff members were observed sitting at a work station assembling trays on 1/30/2017 at 1515.

Staff O was queried on 1/31/2017 at 1012 as to staff availability within the department. Staff O stated that "14 people are off today due to a combination of vacations and FMLA" and that there were "7 call-in's today. We could use another 10 people at least." Staff O was then queried as to why more staff were not hired to which he replied that "all positions within the department had been filled" and added that it was "difficult to find people who are trained" to work within the CSP department. Staff O further stated that "we did have agency (personnel) to help us out, but the union didn't like that."

During an interview with Staff K on 1/31/2017 at 1440, Staff K stated his core staffing levels were 20 instrument associates (IA) for first shift, 35 IA for second shift and 24 IA for third shift. Staff K also had one person working as contingent staff. He stated, "We have a hard time finding qualified staffing." Staff K also stated that he and Staff O worked along side the IA's "on a fairly regular basis" to help process the instrumentation through the department. Additionally, Staff K stated that he has 20 employees currently on intermittent family medical leave (FMLA).

Facility policies regarding timely cleaning of instruments in the CSP decontamination area were requested but not provided prior to exit of survey.