HospitalInspections.org

Based on observation and interview it was determined the facility failed to ensure patient right to privacy was protected in that personal information (name, date of birth, date of service, and hospital record/identification number) for three patients was identifiable on pages of stickers discarded in the biohazard bin beside the lab draw area in the emergency department. The names, date of birth and date of service of three patients were visible to any other patient who had their lab drawn in that area. Findings included:

A. Observation on 10/31/17 at 9:50 AM revealed a large bio hazard disposal receptacle beside a chair used to obtain lab specimens in the Emergency Department. Observation of the contents of the bin, visible from standing or sitting, revealed three different pages of stickers with three different patients' personal information. The information on the stickers included: name, date of birth, date of service and hospital record/identification number. The date of service on each of the three stickers was 10/30/17.

B. On 10/31/17 at 9:52 AM, the Lab Section Head, RN #1 and the Emergency Department Manager confirmed the findings and each agreed the stickers should not have been discarded in the bio hazard receptacle.

Based on observation, review of policies and interview, the facility failed to meet the Condition of Participation for infection control as evidenced by:

1. Failed to ensure a sanitary environment in five of five (Trauma Bay #1, Trauma Bay #2, Lab draw area, outside triage area, and the soiled utility room) areas in the Emergency Department observed on 10/31/17. The deficient practice was likely to expose patients treated in the Emergency Department to sources of infection from opened single use suction tubing, tape and tape residue; dust on equipment and furnishings, failure to separate sterile supplies from non-sterile, and failure to identify biohazards. (refer to A0749)

2. Failed to ensure facility policies were followed by environmental service staff to clean a room after transfer of a patient in isolation on 10/31/17. The failed practice was likely to expose any patient admitted to that room to infection. (refer to A0749)

3. Failed to follow standard precautions during likely exposure to blood or body fluids when starting an intravenous infusion for one of two intravenous attempts observed. The failed practice was likely to cause contamination of the intravenous insertion site. (refer to A0749)

4. Failed to dispose of used lancets in the biohazard sharps container and failed to clean an intravenous access port prior to accessing. The failed practice was likely to expose patients and staff to sources of infection. (refer to A0749)

5. Failed to handle point of care glucose testing equipment after use to prevent cross contamination for one of two bedside glucose tests observed. The failed practice was likely to expose patients who required bedside glucose testing to sources of infection. (refer to A0749)

6. Failed to assure Surgical Services staff in soiled instrument processing wore heavy duty decontamination gloves instead of exam gloves when cleaning instruments. The failed practice did not protect staff from exposure to likely sources of infection. (refer to A0749)

7. Failed to assure soiled surgical instruments were processed to prevent organic matter from drying prior to being cleaned then sterilized in three of three areas observed (Same Day Surgery; 4th Floor OR, and the Emergency Department). The failed practice was likely to affect any patient who had a procedure in which those instruments were used. (refer to A0749)

8. Failed to assure ten (Day Surgery staff #1-#6 and Fourth Floor Operating Room (OR) Staff #1-#4) of eleven (Day Surgery staff #1-#7 and Fourth Floor OR Staff #1-#4) surgical staff observed in the Day Surgery and Fourth Floor Surgical area followed their policy for all hair to be covered in the restricted area of the OR. Failure to assure hair was covered did not prevent the dispersal of likely sources of contamination from staff's hair. (refer to A0749)

These failed practices resulted in patients and staff exposure to likely sources of infection. The cumulative effect of these systemic deficient practices resulted in non-compliance with the Condition of Participation for Infection Control.

Based on observation, review of manufacturer's instructions for use, review of policy and interviews, it was determined the facility failed to protect surgical patients from sources of infection in that it failed to assure instruments transported from the Day Surgery Area, Emergency Department, and fourth floor Operating Room (OR) had pre-cleaning initiated to prevent blood or other organic material from drying on surgical instruments. Failure to assure pre-cleaning was initiated prior to transport to the decontamination area of the Main OR did not assure organic material would be prevented from drying on the instruments. The failed practice had the overall effect of causing the instruments to be more difficult to clean and had the likelihood of decreasing the effectiveness of sterilization for those instruments. Findings included:

A. Review of the facility policy, "Decontamination/Disinfection/Sterilization, Infection Control Policy/Procedure, Policy III. J, Receiving/Decontamination/Cleaning of Supplies," showed:
1) Instruments are to be opened, sprayed with disinfectant or appropriate pre-soak enzymatic solution, covered, and transported to designated areas for decontamination after completion of procedures.
2) Immediate decontamination of instruments was necessary for the protection of personnel and to prevent transmission of pathogens.
3) If transporting to another department for decontamination, spray with disinfectant or enzymatic solution, place in a rigid container with a lid and label as biohazard.

B. Review of the manufacturer's instructions showed the product Pre-Klenz, an instrument transport gel, was used to initiate pre-cleaning without handling instruments and coats soils and maintains moisture. The instructions for use showed to spray evenly over surgical tray to ensure soils are evenly covered. Transport instruments for further processing.

C. Review of the Emergency Department (ED) process for cleaning dirty instruments and observation of the wall of the soiled utility in the ED showed instruments were to be rinsed of all visibly soiled areas in the sink in soiled utility room; sprayed with Pre-Klenz; placed in biohazard bag and then in white plastic container. The posted sign also stated do not allow instruments to dry.

D. Observation in the soiled decontamination area of the main OR on 11/01/17 at 9:48 AM showed one of one cart, identified by the Manager of OR Support as the cart from the Day Surgery Area, with multiple trays of instruments with partially dried blood on the instruments. The Manager of OR Support stated at the time of observation that the instruments should have been sprayed to prevent blood from drying.

E. Observation in the Day surgery area 11/01/17 at 9:51 AM showed at the conclusion of a surgical procedure in OR #1, instruments were layered with surgical towels between the layers. The instruments were sprayed with instrument transport gel on the top layer and were not sprayed over surgical instruments within the tray to ensure soils are evenly coated to prevent drying prior to transport to the main operating room decontamination area. The findings were confirmed at the time of observation by the Nurse Manager for Same Day and fourth floor OR.

F. Observation in the fourth floor OR, on 11/01/17 at 10:38 AM showed at the conclusion of a surgical procedure, instruments were placed in an instrument tray and then lightly sprayed with an instrument transport gel. The instruments were not sprayed to ensure soils were evenly coated to prevent drying. The instruments were placed in a covered tray and transported to soiled holding area within the department. Scrub Technician #1 stated on 11/01/17 at 10:55 AM the instruments may remain in the area prior to transport to the main operating room for decontamination for one to two hours. The findings were confirmed at the time of observation by the Nurse Manager for Same Day and fourth floor OR.

G. Observation on 10/31/17 at 10:06 AM in the Emergency Department soiled utility room showed three of three instruments, two wrapped with a brown paper towel and one that was not wrapped, were dry and not covered with pre-cleaning transport gel. RN #1 was interviewed on 10/31/17 at 10:15 AM and stated the instruments should have been sprayed with the gel and referred to the posted instructions to not allow instruments to dry.



Based on observation, policy review, and interview, it was determined the facility failed to ensure a sanitary environment in five of five (Trauma Bay #1, Trauma Bay #2, Lab draw area, outside triage area, and the soiled utility room) areas in the Emergency Department observed on 10/31/17. The deficient practice was likely to expose patients treated in the Emergency Department to sources of infection from opened single use suction tubing; tape and tape residue; dust on equipment and soiled furnishings; failure to separate sterile supplies from non-sterile; and failed to identify soiled instruments as biohazard. Findings included:

A. Observation of the Emergency Department on 10/31/17 at 9:06 AM, showed:
Trauma Bay #1:
1) Two of three suction tubing packages were open and out of the package; one of three was open but still within the original packaging that was stored with the wall mounted suction canisters. The Suction tubing packaging was labeled as single use only. The integrity or cleanliness of the tubing could not be assured as the packaging was open or missing.
2) Three of three wall mounted suction canisters were observed with tape and tube shaped plastic holders attached with tape. The tape did not allow the outside of the canisters to be cleaned between patients.
3) There was an accumulation of dust on the overflow supply cabinet, beneath the mattress support area of the stretcher, and on the Bair Hugger in the room.
Trauma Bay #2:
4) Observation on 10/31/17 of Trauma Bay #2 showed an accumulation of dust on the upper surface of equipment and furnishings. One of one Advanced Tracheostomy Inducer set with an expiration date of 06/16.
Lab Draw Area:
5) Observation on 10/31/17 at 9:50 AM showed a chair in the lab draw area, available for patient or staff use with one of two arm rests covered with a tape. A cabinet in the area that held lab draw supplies was observed with soiled drip on the front. The bottom rail of chair (where patients sit for blood draw) had an accumulation of dust and dried drips.
Outside the Triage Area (APN Computer):
6) Observation on 10/31/17 at 9:57 AM showed a chair for use by staff with one of two arm rests covered with a tape. A mobile cart that held a computer had an accumulation of dust on the surface. A basket attached to the cart had sterile #20 IV Jelco and partially used rolls of tape stored touching the power supply that was resting in the basket. The power supply was dusty.
Soiled Utility Room:
7) Observation on 10/31/17 from 10:06 - 10:15 AM showed three of three instruments, two of which were wrapped with a brown paper towel, and dried, and one that was not wrapped in a white plastic type bin. The bin did not have a biohazard identification on the outside. During an interview with RN #1 at the time of observation, it was stated the sink in the soiled utility room was used to rinse soiled surgical instruments prior to transport for pre-cleaning. The sink was reported to be used to rinse the instruments was not labeled for instrument processing and had hand-washing supplies.



Based on observation, review of policies and interview, it was determined the facility failed to prevent sources of infection in that one Environmental Services (ES) staff (ES #1) of two (ES #1 and ES #2) failed to follow the policy for cleaning a room after transfer of a patient in contact isolation; failed to prevent contamination of clean linen; and failed to remove gown and gloves to prevent contamination on 10/31/17. Failure to follow the facility policy and infection control standards did not ensure the room was cleaned to prevent exposure of other patients and staff to likely sources of infection. The findings were:

A. Review of facility policy titled, "Seven-Step Cleaning Procedure," with a revision date of 03/2016 showed high dusting was to occur for all horizontal surfaces above shoulder height, starting at the door and working systematically around the room and return to door. This was to included air vents and window ledges. Dust mopping was to occur starting at the farthest corner and work back to the doorway. Damp wipe with disinfectant solution and spot wash walls around switches, doorknobs, etc. with attention to disinfecting problem areas such as drawer fronts and handles. Hard floor surfaces were to be wet mopped prior to setting up the room as required. Discrepancies such as repairs needed were to be reported to unit supervisor.

B. Review of facility policy titled "Discharge Cleaning of Isolation Room," with a revision date of 03/2016, showed in addition to the Seven Step Cleaning Procedure, gloves and isolation gown were to be used, cubical curtains were to be removed and replaced and room set up for next patient.

C. Review of facility policy titled, "Linen Handling," dated 03/04/16 showed clean linen would be handled, stored, and distributed to patients in a sanitary manner.

D. Observation on 10/31/17 at 10:15 AM of ES Staff #1 discharge cleaning of isolation room showed:
1) A section of the laminate was chipped and missing on the corner of the couch area that exposed the wood underneath, which was porous and could not be disinfected. ES Staff #1 did not identify or report the chipped laminate at the conclusion of observation by Surveyor #1 on 10/31/17 at 11:06 AM.

2) High dusting was not performed as required by policy in that the room was not high dusted starting at the door and proceeding systematically around the room; dust moping was not performed to remove debris from floor; and door knobs and cabinet handles were not wiped or sanitized. Staff attempted to replace linen on the bed prior to dust mopping or mopping the floor surface; clean linen for making the bed was carried by ES Employee #1 against her uniform on two separate occasions. When removing her gown and gloves when exiting the patient room, ES Employee #1 touched the back of her hair with soiled gloves when removing the protective isolation gown.

3) At 11:06 AM on 10/31/17, ES Employee #1 stated the room cleaning was finished. Surveyor #1 observed a disposable paper type menu item was left on the air vent. Curtains were not removed for laundering at the time of observation and ES Employee #1 stated they would not be removed.

E. The observation findings and failure to follow policy was confirmed on 10/31/17 at 11:10 AM by ES Employee #1 and Registered Nurse (RN) #5.



Based on observation, review of policy and interview, it was determined the facility failed to ensure ten (Day Surgery staff #1-#6 and Fourth Floor Operating Room (OR) Staff #1-#4) of eleven (Day Surgery staff #1-#7 and Fourth Floor OR Staff #1-#4) surgical staff observed in the Day Surgery and Fourth Floor Surgical area followed their policy for all hair to be covered in the restricted area of the OR. Failure to ensure hair was covered did not prevent the dispersal of likely sources of microorganism from staff's hair. The failed practice affected two OR's observed on 11/01/17 in the Day Surgery area and Fourth Floor OR. Findings included:

A. Record review of facility policy, "Dress Code" with an effective date of 08/2017, showed all personnel within the restricted areas of surgery must wear a cap that covers all hair. Men with long sideburns or beards are required to wear hoods rather than caps in order to cover all facial hair.

B. Observation on 11/01/17 at 9:51 AM of the Day Surgery area showed in the restricted area of OR #1 there were six staff (#1-#6) with hair visible outside the confines of the surgical cap. Day Surgery OR #1, staff #1 also had side burns and arm hair uncovered. The Nurse Manager for Day Surgery and Fourth Floor surgical area confirmed the staff had hair exposed as above at the time of observation.

C. Observation on 11/01/17 at 10:38 AM showed four (#1-#4) Fourth Floor surgical staff in the restricted area had hair visible outside the confines of the surgical cap. The Nurse Manager for Day Surgery and Fourth Floor surgical area confirmed the staff had hair exposed as above at the time of observation.



Based on observation, review of policies and interview, it was determined the facility failed to ensure policies and standard precautions were followed for intravenous access; failed to dispose of used lancet in biohazard sharps container; failed to clean IV port with alcohol prior to accessing; failed to sanitize test strip bottle for point of care glucose testing equipment and failed to handle blood glucose equipment to prevent contamination of uniform after use. Failure of staff to follow standard precautions and policies, did not protect patients and staff from likely sources of infection. The findings were:

A. Review of facility policy, "Infectious Disease Precautions" showed standard precautions is for the care of all patients regardless of their diagnosis or presumed infection status. Clean, non-sterile gloves are to be worn by staff when touching blood, body fluids, secretions, excretions, and contaminated items.

B. Review of facility policy for "Bloodborne Pathogen Exposure Control Plan" with a last reviewed date of 09/2015 showed sharps must be placed in containers which are puncture-resistant, leak proof, and properly labeled."

C. Review of facility policy, "IV Medication and Solution Administration" with an effective date 08/09/17 showed the intravenous access port should be disinfected with an alcohol wipe.

D. Observation on 10/31/17 at 2:07 PM showed Registered Nurse (RN) #4 failed to be completely gloved at the time an intravenous cathlon was inserted into a patient's arm. The index finger of the left hand glove was missing. During interview, RN #4 stated she removed the tip of her glove in order to start the IV and be able to feel the vein. The findings were confirmed at the time of observation by RN #4 and in the presence of RN #5.

E. Observation on 10/31/17 at 4:39 PM showed RN #2 perform a fingerstick blood glucose. The auto-disabling lancet just used was disposed of in the regular trash at the bedside. RN #2 stated during an interview at the time of observation that since the device was auto-disabling it was acceptable to dispose of the device in the regular trash and disposal in a sharps container was not required. RN #5 stated during an interview on 11/01/17 at 3:39 PM that the expectation was that auto-disabling lancets are to be discarded in the sharps container.

F. Observation on 10/31/17 at 11:34 AM showed Nursing Assistant #1 to place a bedside blood glucose machine and strips on the patient's bed. Upon completion of a blood glucose test, Nursing Assistant #1 placed the blood glucose machine under her right arm prior to cleaning the machine after use and proceeded out into the hallway. The bottle of test strips, previously placed on a patient's bed, was dropped onto the floor in the hallway. The bottle of test strips was picked up returned it to the cart by Nursing Assistant #1 without cleaning or disinfecting the outside of the bottle.

G. Observation on 10/31/17 at 10:34 AM showed Certified Registered Nurse Anesthetist (CRNA) #1 failed to clean the IV access port tubing with alcohol prior to accessing.




Based on observation, review of policies and interview, the facility failed to ensure two of two Soiled Instrument Reprocessing Technicians (#1 and #2) wore decontamination gloves when cleaning soiled surgical instruments. The failed practice did not assure two of two staff would be protected from exposure to blood and body fluids during the cleaning of soiled surgical instruments. Findings included:

A. Review of facility policy, "Decontamination/Disinfection/Sterilization, Infection Control Policy/Procedure, Policy III.J" showed for decontamination/physical cleaning, personnel are to wear personal protective equipment; protective eyewear, general purpose utility gloves (not exam gloves), mask, impervious gown or apron.

B. Observation on 11/01/17 at 9:40 AM in the Surgical Services Department showed technician #1 and Technician #2 working in the soiled instrument decontamination area wearing nitrile exam gloves, disposable gown and face mask/shield. Personal Protective equipment observed outside the soiled instrument reprocessing area included heavy duty decontamination gloves (PS 325).

C. On 11/01/17 at 9:42 AM the Nurse Manager for Operating Room Support confirmed Technician #1 and #2 should be wearing decontamination gloves and not the exam gloves as they are too thin.