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Based on observation and interview, the facility failed to ensure that the premises are clean and orderly, resulting in the potential for inadequate cleaning of the premises, increased risk of patient care product contamination for all patients served by the facility.

Findings include:

On May 18, 2016 during the facility tour between 9:00 AM and Noon, observed the following cluttered mechanical spaces and storage areas with items on the floor, inadequate space left for aisles or for working on equipment:

1. Physical Therapy shelving storage area had ten small cardboard boxes with patient supplies (such as diabetic syringes) lying on the floor.
2. Radiology storage was very dusty and dirty with boxes, plastic tubs, a pink Easter bunny and many other items filling the floor space and cluttering both main aisles.
3. Mechanical Room 2 had 15 gallons of concrete sealer, numerous Christmas decorations on top of the air handling equipment, and pieces of wood.
4. The Shower Room in Physical Therapy was being used to store a plastic stepper, which was new in the box and not yet assembled for use in the PT gym. There was also a Saunders lumbar traction device in its box and a cooler bag lying on the floor of the shower.

These findings were confirmed by the Director of Support Services at the time of the inspection.

Based on observation and interview the facility failed to ensure adequate positive pressure ventilation airflow in the central sterile room resulting in the potential for contaminated air to infiltrate into the central sterile room and contaminate sterile supplies that could lead to patient healthcare acquired infection resulting in patient harm for patients served by the facility. Findings include:

1. On May 18, 2016 at approximately 11:30 AM, observed that the central sterile room was under a net negative pressure as indicated by "flutter strip." Specifically, an 8.5 inch x 11 inch sheet of paper held up to the face of the door on the inside of the central sterile room was observed to blow away from the door indicating an obvious flow of air into the room from the general corridor. The facility did have an annual evaluation of the ventilation for the operating room (but not the central sterile room) which documented adequate air changes per hour (ACH) but did not evaluate or confirm proper positive pressure air flow. The positive pressure of the operating room can only be inferred based upon a 19.4 ACH supply air versus a 16.2 ACH return air for the operating room. If the operating room envelope has significant leaks, the positive pressure air flow out of the room can not be guaranteed by ACH measurements but must be documented by relative pressure measurement or other equivalent means (e.g. flutter strip). The facility did not conduct any ventilation testing for the central sterile room. Note: Flutter strip verification of positive pressure air flow out of the operating room was observed on the day of the survey.

This finding was confirmed by the Director of Support Services at the time of the inspection.

Based upon on-site observation and document review by Life Safety Code (LSC) surveyors on 5/17/16, the facility does not comply with the applicable provisions of the 2000 Edition of the Life Safety Code.

See individually cited K-tag below dated 5/18/16 for Life Safety Code.

K-0050

Based on observation, interview and record review, the facility failed to ensure staff followed policies and procedures regarding the labeling of intravenous tubing and hair nets in the food preparation area and failed to ensure availability of hand washing facilities required for controlling infections, resulting in the potential for the spread of infection for all patients served by the facility.

On 5/17/2016 at 0945 it was observed that there was no label on the intravenous (IV) tubing hanging in Patient #1's room. During an interview with Staff C on 5/17/2016, Staff C stated, "They (nurses) are expected to label IV tubing...It shouldn't matter that they are inpatient or an outpatient observation."

On 5/17/2016 at 1448, review of facility policy number 600-9175 entitled, "IV Therapy-Changing Bag, Tubing and IV Site Dressing" was done. On page 3, policy states, "Label the solution and tubing."

On 5/17/2016 at 1255, Staff O and Staff P were observed moving about the entire kitchen area with the front portion of the hair outside of cap/hairnet. On 5/18/2016 at 1015, Staff O and Staff P were seen again in the kitchen area, prepping food with the front portion of the hair not covered by cap/hairnet. In an interview with Staff I on 5/18/2016 at 1235, Staff I stated, "I will talk with them about that." On 5/18/2016 at 1225, Staff C stated, "The expectation would be that they follow policy."

On 5/17/2016 at 1508, review of facility policy number 800-IC15 titled, "Hair Restraints" was done. Policy states, "All hair must be contain(ed) in your hair restraint".





19647

On May 18, 2016 at 11:00 AM during observational tour of surgical floor observed in the surgical suite sink alcove that one of the two required scrub sink stations was filled with a tray from the adjacent Steris System 1E automatic endoscope reprocessor (AER). This effectively made the second scrub sink (which is required by code for infection control purposes) unavailable for use. This finding was confirmed by the Director of Support Services at the time of the inspection.