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Tag No.: A0043
Based on observation, review of available documentation, and interviews with staff, it was determined that the facility failed to have an effective Governing Body legally responsible for the conduct of the facility as an institution.
The Governing Body failed to ensure that the environment was maintained to ensure patient safety as mattresses were torn and available for patient use. Endoscopy snares and biopsy forceps which were available for patient use, were not sterilized per the manufacturer ' s requirements between patients.
Findings were:
1. During a tour of the patient rooms and emergency room conducted on 10-19-11 the mattresses in L2 and L1 had torn covers; the table pad in the suture room also had torn areas and these were not able to be cleaned between patients.
2. During a tour conducted on 10-20-11, the survey team found colonoscopy biopsy forceps which had not been sterilized and were available for patient use. In the past two years there were 43 specimens from 26 patients with these same two alligator clips.
There was no oversight of these areas reported to the governing body. Interview with the hospital administrator confirmed the above in the conference room on 10/21/11.
Tag No.: A0408
Based on review of 32 patient clinical records and interview with staff records # 2 through #17 had verbal and or telephone orders. Fifteen of 15 clinical medical records had verbal and/or telephone orders that were not authenticated within within 48 hours as required by the prescribing physician..
Findings were:
Records #2 through #17 all contained verbal and/or telephone orders which had not been signed dated and timed within the 48 hours as required. Interview with the administrator who also reviewed the records confirmed that the verbal and/or telephone orders had not been signed dated and timed.
Tag No.: A0747
Based observation in surgery and information provided by staff' alligator forceps used in endoscopy procedures had never been sterilized since the processor quit working. The facility failed to ensure that all surgical instruments and devices were processed in accordance with facility policies, manufacturer's recommendation, and/or Center for Disease Control and Prevention (CDC) requirements.
Findings were:
1. During a tour of the surgical suite on 10-20-11, there were unpackaged alligator forceps that had not been sterilized according to manufacturer's directions and CDC requirements and were available for patient use.
Interview with the surgical staff revealed that there was one short alligator clip for the scope used for esophageal and stomach biopsies and the long alligator clip for the colonoscopy scope. These devices are used during a procedure to isolate and remove polyps from the inside lining of the colon (or stomach for the smaller unit) by inserting the device into ports of the endoscopy units.
The devices were observed unpackaged hung in the cabinet available for patient use were manufactured by the Steris system, which specifically require sterilization prior to and between patient use.
The steris device manual states, under Direction for use #3 "Clean and sterilize the forceps for use".
Under "cleaning/sterilization instructions (after following the cleaning instructions) visually inspect the surfaces for cleanliness. Check functionality the jaws should be aligned. Then - Place in a 12 x 12 sterilization pack with indicator. Steam sterilization is used.
Before sterilization, the instrument Since these devices come in contact with blood and body fluids during the polyp removal procedure, the manufacturer instructions, manufacturer operation's manuals, and the Center for Disease Control and Prevention require sterilization of these devices in an autoclave prior to and between patient use.
Interview with the hospital administrator confirmed the above in the conference room on 10/21/11.
The Centers for Disease Control and Prevention (CDC) article, GUIDELINE FOR DISINFECTION AND STERILIZATION IN HEALTHCARE FACILITIES, 2008, by William A. Rutala, Ph.D., M.P.H., David J. Weber, M.D., M.P.H., and the Healthcare Infection Control Practices Advisory Committee (HICPAC), found at:
Tag No.: A0749
Based on interview and review of the Infection control program, it was revealed that there was no monitoring conducted for the use of the endoscopes. Therefore the reuse of the alligator clips without sterilization had not been identified.
Findings were:
Interview with staff and review of the infection control program data revealed that the infection control officer had been unaware of the practice of reuse of alligator clips during endoscopy procedures. There was no data relating to the endoscopy procedures.
Interview with the hospital administrator confirmed the above in the conference room on 10/21/11.
Tag No.: A1538
Based on review of 3 Swingbed records and interview with the swingbed coordinator, 3 of 3 swingbed records failed to have any documentation of a social assesment or interview with the patient as required.
FIndings were:
The swingbed patient records reviewed # 18, 19, 20; had no evidence documented of medically-related social services provided to patients. Reviewing the contract between the facility and the social worker revealed that the included job description requires "Interviws the swingbed patient within 48 hours of admission to the swingbed or prior to the transfer of the patient from the acute unit. The social worker failed to provide services to swingbed patients.
Interview with the hospital administrator confirmed the above in the conference room on 10/21/11.