HospitalInspections.org

Based on observation, interview, record review and policy review the facility failed to keep one piece of emergency medical equipment readily available on one crash cart on the Medical Surgical Unit of one observed for treating emergencies. This failure had the potential to delay treatment in an emergency for all patients, visitors and staff. The facility censes was 18.

Findings included:

Record review of the facility's policy titled, "Crash Carts Replenishment and Maintenance," showed that the House Supervisor was responsible for checking and replenishing the supplies in the crash carts daily and a monthly inventory was performed by the nursing staff to replace missing items.

Observation on 04/09/18 at 3:50 PM on the Medical Surgical Unit showed that the oxygen tank on the crash cart was empty and it was not included in the daily checkoff log.

During an interview on 04/11/18 at 9:00 AM, Staff Y, Director of the Medical Surgical Unit, stated that the oxygen tank should never have been empty and it was not on the check off log. She also stated that the night shift House Supervisor was responsible for checking the crash cart.

During an interview on 04/12/18 at 10:45 AM, Staff G, House Supervisor, stated that the night shift House Supervisor should have checked the crash cart.

This failure had the potential to effect all patients being treated at the facility by the delay of treatment in an emergency. Crash carts should have been fully supplied to include the oxygen tanks and these should have been an important part of the crash cart check log.

Based on observation, interview, record review and policy review, the facility failed to ensure that:
- Policies were reviewed and approved annually by appropriate staff members. (C 272)
- Pharmacy staff followed the infection prevention standards for The United States Pharmacopeia (USP) for compound sterile preparations (CSP). (C 276)
- Crash carts (a set of trays/drawers/shelves on wheels used in hospitals for transportation and dispensing of emergency medications/equipment for life saving protocols) medications were secured when access to disposable plastic locks (allows facility to identify if cart security was breeched) were not controlled and one crash cart was left unlocked. (C 276)
- Breast milk storage refrigerator temperatures were monitored and recorded daily. (C 278)
- Food was properly stored and dated (opened food mix) in the dry goods storage area. C 278)
- Opened food was properly covered and dated in the dietary refrigerator. (C 278)
- Food was properly dated in the dietary freezer for storage. (C 278)
- Staff appropriately handled infectious waste for one biohazard trash can of one observed. (C 278)
- Staff appropriately stored clean linen to minimize contamination. (C 278)
- Staff monitored expired food and log temperatures in the Medical Surgical Unit patient refrigerator. (C 278)
- Staff cleaned and stored 16 laryngoscope blades of 16 observed in crash carts. (C 278)
- Urinals were kept away from food and drink in three patient rooms (#18, #19 and #20) of three observed. (C 278)
- Three opened, expired solutions were removed and not available for use in the ED. (C 278)

The cumulative effect of these failed practices resulted in the facility's non-compliance with requirements of the Condition of Participation: Provision of Services. The facility census was 18.

Refer to the 2567 for additional information.

Based on interview and policy review, the facility failed to develop and/or review policies on an annual basis. This had the potential to affect all acute care and swing bed patients treated or admitted to the facility, by failing to direct appropriate care and services. The facility census was 18.

Findings included:

Record review of facility policy titled, "Policies and Procedures, Protocol for Development," last revised 07//2015 showed direction to staff that:
- Existing policies shall be reviewed on an annul basis and managers should submit recommendation to Hospital Leadership;
- Only policies with revisions need to be submitted; and
- Clinical policies shall be reviewed and approved by the medical director when policies are new or revised.

Record review of the following facility policies showed that:
- "Policies and Procedures, Protocol for Development," was last revised on 07/2015.
- "Organ Donation after Cardiac Death or Non Heart Beating Donation," was effective on 02/2007 and last reviewed on 09/27/2011.
- "Exposure Control Plan," was last reviewed on 07/2016.
- "Storage of Clean Linen," was last reviewed on 12/2015.
- "Processing Procedure of Linens," was last reviewed on 12/2015.
- "Drug Compounding Non Sterile," was last reviewed on 06/2015.

During an interview on 04/10/18 at 9:30 AM Staff L, Chief Nursing Officer (CNO), stated that the physicians did review and signed off on newly created policies but there was no process to have physicians review policies on an annual basis.

During an interview on 04/11/18 at 9:25 AM Staff P, Director of Radiology stated that they don't review all policies once a year but just when there is a need for revision, the medical director of radiology did not usually get involved.

During an interview on 04/11/18 at 2:25 PM Staff C, Director of Quality, stated that they don't review all policies once a year and there was not a committee designated to review policies that had physician membership.

Based on observation, interview and record review, the facility failed to ensure that the pharmacy staff followed the infection prevention standards for The United States Pharmacopeia (USP) for compound sterile preparations (CSP), and failed to ensure medication integrity, when they failed to:
- Decrease the chance of contamination by placing the Biological Safety Cabinet (BSC, a negative pressure unit used to compound hazardous medications), the Primary Engineering Control (PEC, a device or room that provides an environment for compounding medications) in a required ISO class 7 environment, in the Oncology (An area of the hospital designated for the treatment of cancer patients with compromised immune systems) compounding SCA (A separate area designated for compounding chemotherapy medications) by not sealing a window per regulation.
- Maintain the sterility of the inside of the BSC per regulation.
- Apply appropriate personal protective equipment (PPE, gloves, hair covering, shoe covers and gowns) before entering the SCA in the Oncology compounding area.
- Perform and provide a log of the terminal clean (a thorough, deep-cleaning of a room to include the ceiling, walls and floors) of the SCA monthly in the Oncology compounding area for two months.
- Remove all paper products from the SCA in the pharmacy non-hazardous compounding room.
- Ensure staff removed makeup before entering the SCA in the pharmacy non-hazardous compounding room.
- Ensure the integrity of the contents of one unlocked crash cart of five crash carts (a set of trays/drawers/shelves on wheels used in hospitals for transportation and dispensing of emergency medications/equipment for life saving protocols) observed.
- Ensure crash cart medications in four crash carts of five crash carts observed were secured when access to disposable plastic locks (allows facility to identify if cart security was breeched) were not controlled.
These failures had the potential to increase the risk of cross contamination with infection and increase the risk of harm to any patients who received compounded medications and had the potential to allow unauthorized persons access to medications in the crash carts. The facility census was 18.

Findings Included:

Record review of the USP, Chapter 797, dated 2013, showed that:
- The SCA cannot be in a location with unsealed windows/doors that connect to the outdoors.
- The inside of the BSC must remain a sterile environment.
- The BSC must be located in an SCA in an ISO Class 7 environment.
- Particle shedding objects (pencils, corrugated cardboard, paper towels, and cotton items) were prohibited in the SCA.
- Gloves, hair covers, beard covers, gowns and shoe covers were required in the SCA.
- No makeup or jewelry allowed in the SCA.
- The SCA floor cleaning requirements were cleaning the floors and walls daily, ceilings and storage shelving monthly and documented on a cleaning log.

Record review of the facility's policy titled, "Hazardous Medication Handling and Preparation," dated 09/2017, showed direction for staff to follow USP, chapter 797 when compounding hazardous medications.

Observation and concurrent interview with Staff FF, Oncology Nurse, on 04/10/18 at 10:15 AM in the Oncology compounding SCA, showed:
- An unsealed window located within the SCA.
- Inside the BSC was a plastic backed paper pad (particle shedding object) used for mixing the chemotherapy medications.
- Staff FF demonstrated the process of compounding inside the BSC, and left an unsterile glove package laid on top of the plastic backed paper pad.
Staff FF stated that the process was that she opened the sterile gloves, placed the gloves on inside the BSC and left the package inside for mixing the chemotherapy medications. She said that during the donning process of the PPEs, she pulled her hair back with a clip and did not place a hair cover over her hair and did not wear shoe covers. Staff FF also stated that housekeeping did not terminally clean this area.

Record review of the Oncology cleaning log for the compounding area showed that the months January 2018 and March 2018 staff failed to perform terminal cleaning.

Record review of the Oncology compounding log showed 64 chemotherapy (hazardous) medications were mixed in the month of January and 37 chemotherapy (hazardous) medications were mixed in the month of March.

During an interview on 04/10/18 at 10:43 AM, Staff GG, Director of Oncology Services, stated that:
- She was unaware that an unsealed window could not be in the SCA.
- She was unaware of particle shedding object creating contamination inside the BSC.
- She was unaware that the SCA had to be terminally cleaned monthly.

During an interview on 04/11/18 at 4:16 PM, Staff R, Infection Control Nurse, stated that she had no involvement with any of the compounding areas and that the Pharmacist covered these areas.

During an interview on 04/10/18 at 3:38 PM, Staff CC, Pharmacist, stated that she had questioned the window being in the SCA, but was unsure and she had no idea the staff in Oncology were not using hair covers and shoe covers. She also stated that she was unsure of the line of demarcation and cleaning requirements.

Observation on 04/10/18 at 9:30 AM showed Staff EE, Pharmacy Compounding Technician, mixed a non-hazardous compound medication in the compounding room in the pharmacy and the following was observed:
- The Compounding Aseptic Isolator (CAI) was located in a room with a door that served as the line of demarcation.
- Staff EE opened the door, entered, and then donned her PPEs. The boxes (particle shedding objects) of donning materials were hung on the inside of the door and donning inside the room created a contamination from wearing street clothes (contaminated items) inside the SCA.
- Staff EE wore eye makeup into the SCA.
- Paper logs (particle shedding objects) hung on the left wall and a sticky note (particle shedding object) hung on the left leg of the CAI.

Record review of the compounding log for non-hazardous medications showed that the pharmacy mixed an average of 20 medications per month.

During an interview on 04/10/18 at 10:08 AM, Staff EE, Pharmacy Compounding Technician, stated that she was aware of not having paper products in the SCA and no makeup and was unaware of the appropriate line of demarcation.

During an interview on 04/10/18 at 3:38 PM, Staff CC, Pharmacist, stated that she was unaware that a line of demarcation was needed inside the non-hazardous compounding room since it was a closed hood and that staff should always follow their policy on PPEs, makeup and jewelry.

Record review of facility policy titled, "Crash Carts Replenishment and Maintenance," revised 11/2017, showed direction to staff that:
- Drugs for use in medical emergencies shall be available in each patient care area.
- Drugs inside the cart shall remained sealed, at all times, when not in use.
- Drugs are contained in the top three drawers of the emergency crash carts.
- If the crash cart security seal (red lock) has been removed, replacement security seals are located on the top of the crash cart.
- Crash cart checks are done daily and recorded on the crash cart checklist.
- Additional replacement security seals are located in the pharmacy.

Observation in the Emergency Department (ED) on 04/09/18 at 4:10 PM, showed two crash carts, one adult and one pediatric) which were secured with a red, plastic, numbered lock. On top of the crash carts were containers with approximately 20 red plastic, numbered locks, used to secure the crash carts.

During an interview on 04/09/18 at 4:15 PM Staff A, ED Nursing Director, stated that after the crash cart was opened the RN's would restock the items taken out and lock the cart with a new red lock. Staff A stated that when they ran out of locks they would get more from Pharmacy, and to her knowledge, there was no requirement to use the locks in any particular sequence, or where the numbers began or ended. She stated that it was possible for someone to break the lock from the crash cart and remove medications and then replace the lock with one obtained from the container on top.

Observation on 04/11/18 at 10:40 AM in the Nursery showed a Pediatric crash cart secured with red, plastic, numbered locks. On top of the crash cart was a bin with approximately 25 red, plastic, numbered locks.

During an interview on 04/11/18 at 10:45 AM, Staff J, Obstetrics (OB) Director, stated that the bin contained replacement locks for the crash cart and that when more were needed more they would get them from the Pharmacy.

Observation on 04/09/18 at 3:50 PM, on the medical surgical unit, showed that the crash cart was unlocked.

Record review of the crash cart log for the medical surgical unit crash cart, for March and April, showed that 03/01, 03/02, 03/12, 03/18, 03/19, 03/20, 03/28 and 03/29 the crash was not checked. This was eight days of March that staff failed to perform the maintenance check on the crash cart.

Record review of the crash cart log for March and April showed that on the days that were checked, staff answered no to the "Cart locked column". This was 42 days of the crash cart not being locked.

Observation on 04/09/18 at 3:50 PM, on the Medical surgical unit, showed a stack of 10 red plastic numbered locks on top of the crash cart.

During an interview on 04/11/18 at 9:00 AM, Staff Y, Director of the Medical Surgical Unit, stated that the crash carts should have been locked and that it was the night shift House Supervisor's responsibility to perform this check.

During an interview on 04/12/18 at 10:45 AM, Staff G, House Supervisor, stated that night shift House Supervisors were responsible for locking the crash carts.

During an interview on 04/11/18 at 9:45 AM, Staff CC, Pharmacist, stated that the crash carts should have been locked and the red plastic numbered locks were available on top of the crash carts. She also stated that they have no process for tracking the numbered locks.

The unsecured plastic locks and crash cart that was not locked had the potential to allow staff to access the medications in the crash cart without accountability. This rendered the medications unsecured.

These failures had the potential for cross-contamination for all patients that were administered drugs and biologicals from this facility, as well as provide a process for monitoring the crash carts to prevent severe harm to include death.



29511

Based on observation, interview, record review, and policy review, the facility failed to ensure staff followed infection control policies and infection prevention standards when they failed to:
- Clean and store 16 laryngoscope blades of 16 observed in crash carts;
- Properly store and date opened supplies in the Emergency Department (ED);
- Keep three urinals away from food and drink in three patient rooms (#18, #19 and #20) of three observed;
- Monitor and document the temperature of the refrigerator in the Women's Health and Childbirth Center that is designated for breast milk storage on a daily basis;
- Maintain separate storage for the patient and staff members' expressed breast milk;
- Monitor expired food and log temperatures in the Medical Surgical Unit patient refrigerator;
- Properly store and date opened food mix in the dry goods storage area;
- Properly cover and date opened food in the dietary refrigerator;
- Properly date food placed in the dietary freezer for storage;
- Appropriately handle infectious waste for one biohazard trash can of one observed; and
- Appropriately store clean linen to minimize contamination.

These failures had the potential to increase the rate of facility acquired infections for all patients, visitors, and staff. The facility census was 18. The Operating Room (OR) performed approximately 200 procedures per month. The Kitchen served approximately 12-15 patient meal trays per meal, a day.

Findings included:

Even though requested the facility failed to provide a policy on laryngoscope processing or storage in crash carts.

Observation of the ED crash carts on 04/09/18 at 4:10 PM showed four laryngoscope blades in a basin in the bottom drawer of the adult cart. There were four blades in a basin in the bottom drawer of the pediatric (infant/children) cart. The blades were opened and the bin also contained batteries and a variety of other supplies..The bins were dirty. The blades were not packaged in any manner that would indicate that they were cleaned or sterilized.

During an interview on 04/09/18 at 4:15 PM Staff A, ED Nursing Director, stated that the blades are sent for sterile processing after use, but are returned to the ED unpackaged.

Observation on 04/09/18 at 4:00 PM, in the Medical Surgical Unit's crash cart, showed one unpackaged laryngoscope blade placed in an unclean case.

Observation on 04/11/18 at 2:30 PM, in the pediatric crash cart outside of Operating Room (OR) #3 showed seven laryngoscope blades in the first drawer unpackaged and loose.

During an interview on 04/11/18 at 04/11/18 at 4:16 PM, Staff R, Infection Control Nurse, stated that laryngoscope blades should have been either a one time use package or packaged from sterile processing.

Even though requested the facility failed to provide a policy on how to process opened supplies to ensure integrity of the product.

Observation in ED Treatment Room One, on 04/09/18 at 4:20 PM showed two bottles of opened Hydrogen Peroxide (solution used to clean wounds), one had a label with hand written direction to discard 02/17/18, the other had no label. In addition, there was an opened bottle of betadine cleansing solution (also used to clean wounds) with no label that indicated when to discard.

During an interview on 04/09/18 at 4:25 PM Staff A stated that all supplies should be labeled, when they are opened, with the date that they should be discarded, 30 days later.

During an interview on 04/11/18 at 8:15 AM Staff L, CNO, stated that opened supplies should be disposed of 30 days after opened. A label shroud be placed on the item to indicate when it was opened and when it should be discarded.

Observation and concurrent interview on 04/09/18 at 4:15 PM, in Patient #18, #19 and #20's rooms, showed urinals on their bedside tables next to their water and food plates. Staff Z, RN, stated that patients move the urinals to their bedside tables.

During an interview on 04/11/18 at 9:00 AM, Staff Y, Director of the Medical Surgical Unit, stated that the urinals should not have been placed on the bedside tables.

Review of the facility's policy titled, "Breast Milk Collection and Storage," revised 12/21/12, showed that breast milk can be stored in refrigerator for use up to 72 hours post collection, or up to 96 hours post collection if very clean conditions exist when expressed, and that bags/bottles of milk should be labeled with the mother's name, date, and time of collection prior to placing in the refrigerator.

Observation on the Women's Health and Childbirth Center on 04/10/18 at 3:35 PM, showed there were no Refrigerator Logs for temperature documentation of the designated breast milk refrigerator, and staff members stored their personal breast milk in the patient refrigerator.

During an interview on 04/10/18 at 3:35 PM,Women's Health and Childbirth Center Director, stated that:
- The temperature of the breast milk refrigerator is monitored occasionally, but it was not documented anywhere;
- The unit did not have any refrigerator logs;
- The unit nurse was responsible to ensure breast milk was labeled, dated, and timed when any breast placed in the refrigerator for storage; and
- There was currently no patient breast milk in the refrigerator, but one staff member's breast milk was stored there.

During an interview on 04/11/18 at 4:15 PM, Staff R, Infection Control Nurse, stated that:
- Women's Health and Childbirth Center should have a log to document temperatures for the breast milk refrigerator daily;
- She was not aware that staff members stored their breast milk in the patient refrigerator; and
- The facility had a room specifically designated for lactating staff members to use for expressing and storage of their breast milk, complete with a refrigerator.

During an interview on 04/12/18 at 10:00 AM, Staff L, Chief Nursing Officer, stated that:
- Staff should keep a log with dates and temperatures on the refrigerators;
- There was a special room where staff can express their breast milk, and a refrigerator for them to store it in, separate from the patient's refrigerator; and
- That any food stored should be dated.

Review of the facility's policy titled, "Maintenance of Logs for Freezer and Refrigerator Temperatures," revised 03/24/15, showed:
- That freezer and refrigerator temperatures must be checked daily;
- Each nursing unit would designate a staff member to check and record the unit's refrigerator temperature; and
- All temperatures must be recorded on the Temperature Log.

Observation on 04/09/18 at 4:30 PM, on the Medical Surgical Unit's patient refrigerator, showed:
- One chocolate mighty shake with an expiration date of 08/11/17.
- One opened whole milk not labeled.
- One reduced fat milk with an expiration date of 04/08/18.

Record review of the Medical Surgical Unit's patient refrigerator temperature logs, showed:
- In January there were 14 days of no documentation of the temperature checks.
- In February there were 16 days of no documentation of the temperature checks.
- In March there were 10 days of no documentation of the temperature checks.

During an interview on 04/11/18 at 4:16 PM, Staff R, Infection Control Nurse, stated that the refrigerator logs should have been current and it was the CNA's responsibility to check the refrigerators.

Review of the facility's policy titled, "Storage of Patient Food," revised 01/2013, showed direction for staff that nurse aides shall document the patient food freezer and refrigerator temperature daily, and that patient food shall be stored separately from employee food.

Review of the facility's policy titled, "Storage and Use of Leftovers," revised 01/31/18, showed direction for staff to place food into storage containers with lids or completely cover with plastic or foil wrap, and to label with name of the item and date.

Review of the facility's policy titled, "Education - Safe Food Preparation," dated 09/04/15, directed staff that all foods must be covered, labeled, and dated before storing.

Observation in the facility's cafeteria kitchen on 04/11/18 at 09:25 AM, showed:
- There was an open, undated bag of powdered, sugar free, custard mix stored in the dry goods area with only a twist tie closure;
- In the refrigerator, an undated block of queso cheese was loosely wrapped with cling wrap, over only one end of the block;
- In the freezer area, was an entire tray of undated, individually wrapped angel food cake slices.

During an interview on 04/11/18 at 9:30 AM, Staff M, Dietary Director, stated that the expectation would be that all food would be dated and covered appropriately before being stored in the dry goods area, refrigerator, or the freezer. And the patient care units were responsible for maintaining and checking their patient refrigerators for cleanliness, temperatures, dates, open and expired food items.

Record review of the facility's policy "Infectious Waste Policy," dated 10/2016, showed that:
- Isolation waste was waste generated by hospitalized patients who have a communicable disease capable of being transmitted to others.
- Infectious waste was to be managed in a manner that protected the health of employees and consumers consistent with regulation.
- All staff that generated infectious waste were responsible for proper handling that ensured no cross-contamination.

Record review on 04/09/18 of Patient #5's medical record, showed that the patient was admitted on 04/09/18 at 1:02 PM and tested positive for Influenza A and B virus (Both very contagious) and placed on Droplet precautions.

Observation on 04/09/18 at 3:57 PM showed a biohazard trash can with no lid (exposed to other patients, staff and visitors) in the hallway outside of Patient #5's room. Droplet (isolation precautions, gown, mask and gloves) and contact precautions (gown and gloves) were posted on the patient's door.

During an interview on 04/11/18 at 9:20 AM, Staff Z, Registered Nurse (RN), stated that hazard trash cans need to stay in the patient's room and not in the hallway.

During an interview on 04/11/19 at 9:50 AM, Staff DD, Certified Nursing Assistant (CNA), stated that she was trained to keep all of the hazard trash cans inside of the patient's room.

Record review of the facility's policy titled, "Storage of Clean Linen," showed the direction for staff to have a place to keep clean linen to minimize microbial contamination from surface contact or airborne particles.

Observation on 04/09/18 at 3:50 PM on the Medical Surgical Unit hallway, showed a three tier linen cart with no covering (risk of contamination).

During an interview on 04/11/18 at 9:50 AM, Staff DD, CNA, stated that she brought the linen cart into each of the patient rooms whenever she gave them a bath (exposed all patients to cross contamination).

During an interview on 04/11/18 at 9:00 AM, Staff Y, Director of the Medical Surgical Unit, stated that the linen carts should have been covered and the technicians should not have brought them in the patient's rooms.

These failures had the potential to effect staff, visitors, and every patient treated at this facility by increasing their risk for exposure to infectious organisms.











36473




29511

Based on observation, interview, record review, policy review and review of the Association of PeriOperative Registered Nurses (AORN) and the Association for the Advancement of Medical Instrumentation (AAMI), the facility failed to:
- Maintain a sterile (free of harmful contaminants) environment in the operating room (OR) Suites (#1, #2 and #3), by failing to terminally clean (a cleaning method used in hospitals to control the spread of infection) the areas daily.
- Maintain a sterile environment in the OR Sterile Processing Department (SPD, where contaminated surgical equipment and instruments were cleaned and wrapped) clean and dirty rooms, which processed instruments used in all OR suites, by failing to terminally clean the areas daily.
- Maintain a sterile environment in the SPD clean and dirty room by leaving multiple paper products (particle shedding products that can cause contamination) in the rooms.
- Maintain a sterile environment prior to surgery by placing contaminated objects on Patient #17's surgical bed.
- Maintain sterilization placing a contaminated stethoscope on patient #17's chest in OR #1 during a surgical procedure;
- Maintain the cleanliness of one laryngoscope blade (equipment that allowed visualization of the vocal cords prior to intubation [placement of a breathing tube] for Patient #17 prior to surgery)
- Remove jewelry and watches before entering the surgical area.
These failed practices had the potential to expose all patients, visitors and staff to cross contamination and increased the potential to spread infection as well as effect the surgical outcomes. The cumulative effect of these failures resulted in non-compliance with 42 CFR 485.639 COP: Surgical Services. The facility census was 18.

Findings included:

Record review of the facility's policy titled, "Scope of Services," showed that the AORN and AAMI were followed for procedures and standards of practice in the Surgical Services Department.

Record review of the AORN, "Terminal Cleaning In Sterile Processing," dated 2014. showed the directive that the sterile processing rooms were to be terminally cleaned daily, the same as the operating, delivery and invasive procedure rooms.

Record review of the facility's policy titled, "Cleaning the Surgery Department," showed directives for staff to perform end of shift cleaning as follows:
- Clean all scrub sinks and fixtures beneath the sinks with a germicidal solution.
- Clean all offices, support areas, lounges, restrooms and locker rooms.
- Replenish supplies as necessary.
- Continue between cases cleaning as necessary.
The direction for OR staff was to perform between case cleaning and not perform terminal cleaning daily that included the ceilings. This is a direct contradiction to AORN standards.

Record review of the terminal cleaning chart for 2018, showed that OR#1, OR#2, OR#3, and the SPD clean and dirty room were terminally cleaned one time per month.

Record review of the surgical log for 2018 showed that:
- In January there were 225 surgeries performed.
- In February there were 212 surgeries performed.
- In March there were 217 surgeries performed.

During an interview on 04/11/18 at 1:10 PM, Staff U, Director of Surgical Services, stated that in between cases, the lights and floors were cleaned and at the end of the day walls were cleaned and that they only cleaned the ceiling one time per month.

During an interview on 04/11/18 at 3:48 PM, Staff BB, Chief Executive Housekeeper, stated that the three OR suites were terminally cleaned monthly and the SPD clean and dirty rooms were terminally cleaned quarterly.

Record review of the AAMI, "Water For The Reprocessing Of Medical Devices," dated 08/2014, showed that the sterilizer's water hardness could affect the purity of the steam used and could carry over the excessive chemicals into the steam used for sterilization and these were to be cleaned per manufacturer's recommendations.

Record review of the main sterilizer's manufacturer manual (Steris Amsco C Series Steam Sterilizer) gave the direction to:
- Clean the chamber drain strainer at least one time per day before the first cycle.
- Clean the chamber periodically to maintain cleanliness and appearance.
- Staff to determine appropriate cleaning intervals based on the local water conditions and chamber appearance.
- Have the chamber professionally cleaned yearly to maintain the appearance of the interior.

Observation on 04/11/18 at 1:45 PM in the SPD clean room, inside the main sterilizer, showed residue in the front and discoloration on the back wall with brown streaks.

Although requested the facility was unable to provide a cleaning log and maintenance log for the main sterilizer.

During an interview on 04/12/18 at 9:38 AM, Staff U, Director of Surgical Services, stated that:
-The manufacturer's (Steris) representative told her that they could not provide proof of maintenance or cleaning of the sterilizer.
- The staff did not clean the sterilizer.
- The staff had no log of maintenance or cleaning.
- The staff did not perform any water testing for water hardness.

During an interview on 04/11/18 at 4:16 PM, Staff R, Infection Control Nurse, stated that the manufacturer's recommendations were that the sterilizers were to be cleaned one time per year.

Observation on 04/11/18 at 1:30 PM in the SPD dirty room showed a piece of paper (particle shedding) and a clipboard with multiple papers (particle shedding) on the counter.

Observation on 04/11/18 at 1:35 PM in SPD clean room showed:
- Clipboard with multiple papers (particle shedding) on the counter next to the instrument wrapping area;
- Two cups of pencils (contaminated objects) on the counter next to the instrument wrapping area;
- Three boxes (particle shedding) of supplies on the counter next to the instrument wrapping area;
- One stainless steel roller cart (contaminated object) that was visibly dirty on the bottom shelf;
- Storage shelves with six paper boxes (particle shedding); and
- One large pegboard with multiple papers (particle shedding) hung on the wall.

During an interview on 04/11/18 at 2:15 PM, Staff U, Director of Surgical Services, stated that the SPD rooms were cluttered and was unaware of particle shedding. She also stated that this had been the practice for 40 years.

Observation on 04/11/18 at 11:00 AM, in OR #1, Staff AA, Surgical Technician's preoperative setup showed:
- Staff AA scrubbed in and applied PPEs.
- She then retrieved the packaged surgical instruments from a table outside of the OR.
- She opened the packages and dropped the surgical instruments onto the sterile table.
- After she opened each package, she then placed the packages on Patient #17's clean surgical bed.
The outside of those packages were contaminated from being exposed to the hallway and thus contaminated the patient's bed.

During an interview on 04/11/18 at 2:02 PM, Staff AA, Surgical Technician, stated that they have always placed the packages on the patient's bed and that we all did it.

Observation on 04/11/18 at 11:10 AM, in OR #1, showed:
- Staff W, Registered Nurse (RN), wore a necklace.
- Staff V, Circulating RN, wore a necklace, earrings and rings.
- Staff T, Surgeon, Chief of surgery, wore a necklace and earrings.

During an interview on 04/11/18 at 11:05 AM, prior to entering the OR, Staff T, Surgeon, stated that she has performed surgeries for 25 years and no one has ever said anything to her about her jewelry. She also stated that she has never had a surveyor look at a physician.

During an interview on 04/11/18 at 1:40 PM, Staff V, Circulating RN, stated that she was aware of the jewelry policy and since she wasn't close to the patient she thought it was ok.

Obervation on 04/11/18 at 11:10 AM, in OR #1, showed that Staff X, Anesthetist, wore a contaminated stethoscope (not cleaned prior to entering the OR) and a watch during the procedure. Staff X also opened the sterile laryngoscope blade (equipment that allowed visualization of the vocal cords while a breathing tube was placed) and laid it on Patient #17's bed (contaminated object) before intubation (placement of a breathing tube) of the patient.

During an interview on 04/11/18 at 1:30 PM, Staff X, Anesthetist, stated that he wore his watch all of the time and he cleaned his stethoscope as needed. He also stated that he did not think anything about laying the laryngoscope blade on the patient's bed since the patient's mouth was already dirty.

During an interview on 04/11/18 at 1:10 PM, Staff U, Director of Surgery, stated that staff should have followed policy and removed jewelry before entering the OR and was aware that the surgical technicians placed the instrument packaging on the patient's bed.

During an interview on 04/11/18 at 4:16 PM, Staff R, Infection Control Nurse, stated that she had made Staff X aware of the laryngoscope blade being kept clean in surgery and he told her that since the mouth is not sterile, it was not a problem. She also stated that there was no reason to wear a watch with a clock in each of the ORs and staff should have followed policy per wearing jewelry and cleaning the stethoscopes.

These failures had the potential to affect all patients that had surgical procedures at this facility, to include negative effects on patient's long and short-term outcomes.

Based on observation, interview, and record review, the facility failed to complete comprehensive patient assessments for activities offered to swing bed patients (a specific type of reimbursement program for patients that require a skilled service, like therapy, but do not require acutethe care) for a total of five current swing bed patients admitted. This had the potential to negatively impact the quality of life for the swing bed patient during their admission to the facility by failing to individualize activities to each patient's preference.
The total facility census was 18, which included five swing bed patients.

Findings included:

During interview and concurrent record review on 04/10/18 at 10:00 AM, Staff C, Quality Director, revealed:
- The comprehensive activities assessment was populated by the charting that the nurse aides document on each patient under Activities of Daily Living (ADL);
- Documentation that Patient #6 had watched television, and worked on puzzles at different times during a shift;
- That the Activities Director, Staff K, would be able to show more complete documentation of comprehensive activities assessment, but he was unsure where she documented that information in the electronic medical record;
- That there is not a formal Activities Calender, there had been one previously, but the facility found that there was not a reason to have such a regimented program of activities given the short stay of their patient; and
- Patients are offered a variety of activities, including magazines, books, puzzles, and crosswords.
During an interview on 04/12/18 at 8:30 AM, Staff K, Occupational Therapist, Activities Director, stated that:
- She just found out on 04/11/18 that she was the Activities Director;
- A formal activities calander does not exist;
- Staff C, Director of Quality, was the staff member who determined what activities would be offered and were available to patients;
- No comprehensive activities assessment exists, prior to changing over to the electronic medical record, there had been a lengthy assessment that was completed by the nursing aides, but when they switched, it disappeared;
- She had asked about the assessment when the electronic charting began, and was told that it wasn't necessary; and
- There is no formal charting of likes/dislikes of the patients; the only documentation is that of the nurse aides under the ADL charting.

This had the potential to negatively impact the quality of life for every patient admitted to swing bed status at this facility.