HospitalInspections.org

Based on interview and record review the hospital governing body failed to ensure hospital staff followed policies and procedures for the training and competency of 2 of 8 contracted employees (staff W and X).

Findings include:

The governing body failed to ensure that the services performed under contract are provided in a safe and effective manner. See A-0084

The systemic effect of this deficient practice has the potential to affect the quality of care received by all patients at this facility during this survey

Based on record review and interview, the facility failed to evaluate the quality of each contracted service in 2 of 2 contracted services (Environment Services/Housekeeping) utilized by the facility.

Findings include:

Review of the facility EVS "New Hire Orientation Hourly Training" Policy #4.03 dated 6/1/2014, revealed "Purpose: Execute and review new hire orientation training for all new associates to ensure accreditation, compliance, associate understanding and competency. Procedure: Training should cover every task related to hourly associate responsibility."

Review of the facility EVS "Annual Hourly Training" Policy #4.02 dated 6/1/2014, revealed "Purpose: Execute and review training aspects to ensure accreditation compliance, associate understanding and competency. Procedure: Training is mandatory for all hourly associates on an annual basis. Training should cover every task related to hourly associate responsibility."

Review of the facility EVS "CHAT (Communication, Help and Training)" #4.0 dated 6/1/2014, revealed "Purpose: Execute and provide training monthly in coordination with accreditation expectations to ensure associate awareness and competency. Procedure: Deliver Monthly CHAT session and record attendance using the CHAT Attendance Verification Sheet."

Review of "Mygreat (sic) START New Associate On-boarding Plan: EVS" revealed training plan sign-off labeled "SAFETY" that includes the following: "Infection Control and Awareness a.) Standard and Universal precautions b.) Bloodborne pathogens..." Facilitator sign off indicates this person has demonstrated knowledge (i.e. can recite back) and/or skill (i.e. has carried out task while being observed)." There were no Infection Control and Awareness "Facilitator sign offs" documentation for contracted EVS employees W and X.

Review of the contracted EVS quarterly "OSHA Bloodborne Pathogens/Infection Prevention" training logs for year 2020, revealed no documentation of attendance for contracted EVS employees W and X.

Review of the "CHAT" EVS training log and staff attendance, dated 3/3/2021 revealed that the EVS CHAT training topic discussion was "March Chat Bloodborne Pathogens." There was no documentation for contracted EVS employees W and X in attendance.

Review of the facility contracted [name] Staffing Schedules for the past 3 months revealed that contracted EVS employee W was on the ED (Emergency Department) Housekeeping schedule on the following dates: 2/23/2021-2/25/2021, 3/3/2021-3/6/2021, 3/8/2021-3/11/2021, 3/15/2021 and 3/16/2021. Contracted EVS employee X was on the OR (Operating Room) Housekeeping schedule on the following dates: 1/11/2021-1/15/2021, 1/18/2021-1/22/2021, 1/25/2021-1/29/2021, 2/1/2021-2/3/2021, 2/5/2021, 2/8/2021-2/12/2021, 2/22/2021-2/25/2021, 3/1/2021-3/5/2021, 3/8/2021-3/12/2021, 3/15/2021 and 3/16/2021.

EVS employee W worked as a housekeeper in the Emergency Department 13 days in February and March 2021. EVS Employee X worked 42 days as a housekeeper in the Operating Room between January-March, 2021. Neither contracted employee had training in blood-borne pathogens or handling infectious waste.

Review of the facility "[name] Hospital- Board Quality, Safety, and Service Committee minutes" dated 9/4/2020, revealed presentation of "CSM FY20 Annual Contracted Services Report" and the "ACSM Clinical Contracted Services Summary." There were no reports attached to the minutes to reflect that EVS Contracted Services were discussed.

Review of the contracts for the [name] contracted services with the facility revealed "Company represents and warrants that all Assigned Employees provided will have the experience and training for the services hired. 4.2. Committed Customers' Responsibility: Committed customers shall adequately instruct and supervise Assigned Employees and Same-Day Hires in performing the agreed upon Services in an attended environment. Additionally, the Committed Customers shall provide any general or specific safety training necessary to perform the Services."

During an interview with EVS Director E on 3/16/2021 at 12:15 PM, when asked about EVS services and training provided, E stated "EVS staff work through [name of company] that is contracted with the facility, EVS staff does computer training for Bloodborne pathogen and orientation prior to cleaning. Stericycle is a contracted company in charge of the biohazard sharps containers on the wall, 3 days per/week there are technicians that monitor and replace these-EVS staff can also pull these if needed."

During an interview with EVS Contracted Employee W on 3/16/2021 at 12:21 PM, when asked W who [he/she] works for and training received, W stated "I am an employee hired through the [name] Temporary Agency, I have been working here for about 1 month. When asked about training, W stated "I worked beside staff for 4 days and watched 3 different staff clean ED rooms. When asked W about Bloodborne Pathogen training or any infectious waste training, W stated "What training? Nobody said I need this training."

During an interview with EVS Director E on 3/16/2021 at 12:30 PM, when asked E about the [name] Temporary Agency, E stated "It is a temp agency that contracts with [name] facility."

During an interview with EVS Office Manager G on 3/16/2021 at 2:45 PM, when asked G about job duties for EVS Contracted Employee W and what training [he/she] had, G stated "Staff W was hired as a 'floor tech' and should have not been cleaning rooms. Floor techs work in corridors and work on floors, not in patient rooms. The lead Housekeeper gave EVS Employee W permission to clean ED (Emergency Department) rooms this morning, EVS Director E was not made aware."

During a phone interview with EVS Director E on 3/18/2021 at 1:00 PM, when asked E who is responsible for staffing and training of EVS contracted staff, E stated "Ultimately I am responsible for all EVS staffing, the Housekeeping Supervisors report to me. My Office Manager G makes up the monthly staffing schedules and I look them over for imbalances. Training falls under the responsibility of [name] contracted company, not under [name] facility. New employee orientation starts with the 'Mygreat START' on-boarding plan that contains Bloodborne pathogens training for Housekeepers." When asked E who decides what duties EVS staff do when on their assigned floor, E stated "The Housekeeping Supervisors do, but all of this falls on my shoulders."

During a phone interview with Operations Manager J on 3/18/2021 at 2:45 PM J stated "I oversee the floors (nursing units)." When asked J about EVS staff placement on the floors, J stated "Usually they are assigned to primary areas, if we have call-offs we have to make adjustments." When asked J about EVS contracted employee W and where [he/she] works, J stated "EVS employee W was originally hired for the floor tech position, we started having staffing issues so we reassigned [him/her] to the ED in about the second week on the floor. I did inform the EVS Director E that I needed to reassign [him/her] and that [he/she] needed to go through the training to be a Housekeeper. This one slipped through the cracks, there hasn't been confirmation that training has been done for EVS Employee W."

During a phone interview with Assistant Director K on 3/18/2021 at 4:15 PM, K stated "I have been the EVS Assistant Director for almost 3 years, I cover the OR and manage the Housekeeping staff on 2nd shift." When asked K if all Housekeeping staff are required to have the Bloodborne pathogen training, K stated "Yes, our Housekeeping all have Bloodborne pathogen training. When asked K about EVS Contracted Housekeeping Employee X that is staffed in the OR, K stated "Housekeeper X hasn't been through the Bloodborne pathogen training, we recently lost a manager on 2nd shift and this happened in their absence. EVS Director E did inform me that EVS Housekeeper X was not trained."

During an interview with Quality Manager C on 3/18/2021 at 4:15 PM, when asked C how the Governing Body ensures contracted services are competent and trained to complete services in the contract, C stated "The annual review of contracts happened during the Board Quality, Safety and Service Committee meetings that provides oversight and reviews our contracted services as requested-the committee meets monthly. When asked C about the status of receiving the contract for [name] company, C stated "Legal is looking into sending certain areas requested in regards to services provided and training, they will not release the entire contract."

Based on observation and interview, facility staff failed to maintain a clean and sanitary environment free from potential sources of contamination on 1 of 1 Hospital unit observed (Emergency Department).

Findings include:

During a tour of the Emergency Department (ED) with ED Manager D on 3/16/2021 at 11:05 AM, Room #44 had an open bucket red biohazard bag with 2 IV (Intravenous) catheters inside. There was a sign on the outside of the room that read "Room has been disinfected by Housekeeping, ready for patient care."

Review of the facility policy titled, "Infectious Waste Plan, AW" #8631506 dated 09/2021 revealed, "Infectious waste includes the following: Bulk blood and body fluids from humans. Segregation of Infectious Waste: Infectious waste shall be discarded into clearly identifiable containers or plastic bags. Red plastic bags will be used for infectious waste. Containers will be red in color and marked with the universal symbol for biological hazards. The Environmental Services departments or contracted cleaning services will be responsible for the storing, transporting, treating and disposing of Infectious Wastes. Collection/Transportation of Infectious Waste/Pathological Waste: The frequency of daily infectious waste collection shall correspond to the quantities of the infectious waste generated to ensure that these bags are not overfilled."

Review of the facility EVS "Infectious Waste Identification Procedure" Procedure 8.01 dated 1/1/2019, revealed "Purpose: To identify all areas that may potentially generate infectious waste. Procedure: Infectious waste shall be defined as: All waste material such as syringes, needles, swabs, soiled dressings, culture plates, paper towels and used gloves generated in and by the areas listed (Surgery, Labor and Delivery, Pathology, Laboratory, Central Service, Lithotripsy, Morgue, Designated Isolation Rooms, Dialysis, Patient Clinical, Diagnostic Testing Areas and Emergency Department) and will be considered as potentially infectious and handled as infectious waste. Any items saturated or dripping with blood or body fluids. All material generated from the listed areas above will be placed in red bags and handled according to departmental procedures."

Review of the facility EVS "Infectious Waste Removal and Transportation" Procedure 8.02 dated 1/1/2019, revealed "Purpose: To handle and transport infectious waste in compliance with all Federal, State and local guidelines. Equipment: All containers used for temporary storage shall be lined with red bags labeled Infectious Waste. Procedure: Infectious waste shall be bagged in durable red liners and labeled Infectious Waste."

During an interview with ED Lead RN O on 3/16/2021 at 11:30 AM, when asked O when red open buckets are emptied and when rooms are ready, O stated "EVS should be emptying them anytime there is something in them, I wouldn't expect to see IV tubing in an open bucket in a 'clean' room."

During an interview with ED RN P on 3/16/2021 at 11:59 AM, when asked P if Room #44 was ready for patient care, P stated "This room is not appropriate for a patient room, open buckets should be emptied every time after each patient."

During an interview with ED Manager D on 3/16/2021 at 12:10 PM, when asked D when red open buckets are emptied, D stated "EVS is responsible for emptying those bags after every patient leaves the room, if EVS is not available then staff would empty-the room would not be ready for the next patient if not emptied."

During an interview with Infection Preventionist H on 3/16/2021 at 3:15 PM, when asked about infection control practices in the rooms and red biohazard bag removal H stated "There are biohazard bins on the walls for sharps or anything sharp that punctures. There are bins with lids and open buckets with red bags that things like bloody gauze go into. Anything left in the open kick bucket bags from previous patients must be emptied."