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Based on observation, interview, and record review, the hospital failed to:
1. Ensure gowns with metal snaps were not stored in the warming unit with incorrect temperature.

2. Ensure the warming unit was maintained at the correct temperature.

These failures had the potential for patients to receive a burn from the heated metal snaps.

Findings:

1. During a concurrent observation and interview with Registered Nurse (RN) 6, on 5/16/16, at 2:20 PM, in the GI (Gastrointestinal- area where procedures are performed on individuals to examine the food pipe, stomach, and small intestine) laboratory, the temperature on the warming cabinet read 144° (degrees) Fahrenheit (F). Inside the warming cabinet was a patient gown with metal snaps. RN 6 stated "That (gown) shouldn't be in here." RN 6 verified the temperature of the warming cabinet.

2. During an observation on 5/16/16, at 2:45 PM, in the Emergency Room, the warming cabinet (top chamber) temperature read 141° F. The Director of Emergency Services (DES) verified the findings. The DES made no further comment.

The hospital policy and procedure titled: "Warming Parenteral, Irrigation, Peritoneal Dialysis Solution and Patient Care Blankets," revised date 2/2014, indicated: "A. Warming Recommendations 4. Patient Care Blankets a. Patient care blankets can be warmed to temperatures up to 130° F. B. 1. Warming cabinets will be monitored on a daily basis in compliance to recommended temperature ranges."

Based on observation, interview, and review of its infection control and prevention program, the hospital failed to monitor and collect information of a construction area located in the sterile processing area. This failure had the potential to compromise the sterility of the surgical supplies and instruments.

Findings:

During a tour of the hospital's Central Sterile Processing Area, on 5/17/2016, at 9 AM, with the Project Manager for Construction (PM), Epidemiologist (EPI), Sterile Processing Supervisor (SPS), Chief Nursing Officer (CNO), and Director of Preoperative Services (DPS), a plastic barrier, 42 feet long by 12 feet high, which separated a construction area from the rest of the central processing area was observed. Inside the construction area, there were exposed pipes due to missing ceiling tiles. The base of the plastic was not secured to the floor which allowed air to lift the barrier off the floor. There were multiple holes in the plastic barrier which were covered with tape. Air was blowing from the construction area into the Central Sterile Processing area. Directly adjacent to the plastic barrier were a number of stainless steel wire carts containing sterile supplies and surgical packs, waiting to be transported to the operating room for patient use. It was also observed there were several "crash carts" stored directly adjacent to the plastic barrier. When the carts, crash carts and stainless steel storage carts were wiped with a clean white cloth, there was a visible black residue on the cloth, indicating possible contamination of sterile supplies on the carts.

During an interview with EPI, CNO, DPS and the SPS, on 5/17/16, at 9:30 AM, they were not aware of the amount of dust and dirt recovered. The EPI then provided a hospital policy and procedure titled "Infection Control Construction Permit". This permit, dated 3/22/16 and posted next to the construction site, indicated the construction would be completed within two weeks and would be "small scale, short duration" and at "Medium Risk". The purpose of the construction was to repair and fix the leak in the area from a flooding incident occurred in September last year. The work would involve major demolition and new construction of the area and would affect all patients seeking treatment at the hospital (also called Class IV construction requiring the most protective measures to minimize risk of hospital acquired infections). The Permit posted next to the construction was marked as a "Class 2." However, review of the hospital "Infection Control Risk Assessment Tool" revealed Sterile Processing Department was in Group 4, the highest risk area for infection control.

During interviews with the EPI and the SPS, on 5/17/16, at 9:45 AM, the hospital staff stated the daily inspections had not been performed because of the expected short duration of the construction. A state of Immediate Jeopardy was declared because the dust and dirt contamination could not be consistent with sterile surgical supplies and equipment.

Based on observations, interviews, and review of documents, the hospital's governing body failed to assume the legal responsibility to ensure its quality assurance and performance improvement program addressed the condition of the construction area in the Sterile Processing Department as cited in the original re-certification survey.

This failure had the potential to affect the sterility of ready-for-patient-use surgical supplies and sterile surgical packs stored in the Sterile Processing Department and unsafe care to all patients in the hospital.

Findings:

During a tour of the central processing area of the hospital, on 5/17/2016, at 9 AM, with the Project Manager for Construction (PM), the Epidemiologist (EPI), the Sterile Processing Supervisor (SPS), the Chief Nursing Officer (CNO), and the Director of Preoperative Services (DPS), the condition of the old autoclave (equipment used to sterilize surgical tools) area was inspected. It was observed that sterile supplies were stored on numerous stainless steel storage carts and several crash carts outside the construction area. A plastic barrier covered the outside of the construction area to contain the dust and debris caused by the construction. There were several tears in the plastic barrier held together by construction tape. The barrier was not secured to the floor by paper tape and left enough space for air to blow from the construction area to the Sterile Processing Department. The PM stated the duration of the construction should have been only two weeks, starting 3/22/16.

The policy and procedure on "Construction/Renovation and Infection Control" was reviewed on 5/17/16. The hospital's policy and procedure indicated the PM and contractor were responsible for "daily compliance monitoring per Daily Monitoring Form."

During an observation on 5/17/16, at 9:30 PM, when the carts, crash carts and stainless steel storage carts were wiped with a clean white cloth, there was a visible black residue on the cloth, indicating possible contamination of sterile supplies on the carts. The EPI, CNO, the DPS and the SPS were not aware of the amount of dust and dirt generated by the construction.

During interviews with the EPI and the SPS, on 5/17/16, at 9:45 AM, both stated the daily inspections had not been performed because of the expected short duration of the construction.

Based on interview and record review the hospital failed to:

1. Have a discharge plan for one (3) of 30 sampled patients.

2. Have a discharge plan in a timely manner for one (4) of 30 sampled patients.

This failure had the potential to have patients needs go unmet.

Findings:

1. During an interview with the Director of Telemetry (DT), on 5/17/16, at 4:25 PM, she reviewed the electronic medical record (EMR) for Patient 3. Patient 3 was admitted on 5/13/16 at 5:20 PM. The DT was unable to find a discharge planning assessment.

2. During an interview with the DT, on 5/17/16, at 4:45 PM, she reviewed the EMR for Patient 4. Patient 4 was admitted on 5/6/16, and initial discharge planning assessment was done on 5/12/16 (six days later). The DT verified the findings.

The hospital policy and procedure titled "Discharge Planning" review date 1/2015, indicated "B. Each patient will have a Discharge Planning Assessment completed by Case Management Staff (Case Manager, Social Worker, and/or Discharge Planner) within 24 to 48 hours upon admission..." I. Discharge Planning is an on-going process in which patients are re-assessed... Re-assessment will be done every 4th day from their last assessment."

Based on observation, interview, and record review, the hospital failed to:
1. Ensure gowns with metal snaps were not stored in the warming unit with incorrect temperature.

2. Ensure the warming unit was maintained at the correct temperature.

These failures had the potential for patients to receive a burn from the heated metal snaps.

Findings:

1. During a concurrent observation and interview with Registered Nurse (RN) 6, on 5/16/16, at 2:20 PM, in the GI (Gastrointestinal- area where procedures are performed on individuals to examine the food pipe, stomach, and small intestine) laboratory, the temperature on the warming cabinet read 144° (degrees) Fahrenheit (F). Inside the warming cabinet was a patient gown with metal snaps. RN 6 stated "That (gown) shouldn't be in here." RN 6 verified the temperature of the warming cabinet.

2. During an observation on 5/16/16, at 2:45 PM, in the Emergency Room, the warming cabinet (top chamber) temperature read 141° F. The Director of Emergency Services (DES) verified the findings. The DES made no further comment.

The hospital policy and procedure titled: "Warming Parenteral, Irrigation, Peritoneal Dialysis Solution and Patient Care Blankets," revised date 2/2014, indicated: "A. Warming Recommendations 4. Patient Care Blankets a. Patient care blankets can be warmed to temperatures up to 130° F. B. 1. Warming cabinets will be monitored on a daily basis in compliance to recommended temperature ranges."

Based on observation, interview, and review of its infection control and prevention program, the hospital failed to monitor and collect information of a construction area located in the sterile processing area. This failure had the potential to compromise the sterility of the surgical supplies and instruments.

Findings:

During a tour of the hospital's Central Sterile Processing Area, on 5/17/2016, at 9 AM, with the Project Manager for Construction (PM), Epidemiologist (EPI), Sterile Processing Supervisor (SPS), Chief Nursing Officer (CNO), and Director of Preoperative Services (DPS), a plastic barrier, 42 feet long by 12 feet high, which separated a construction area from the rest of the central processing area was observed. Inside the construction area, there were exposed pipes due to missing ceiling tiles. The base of the plastic was not secured to the floor which allowed air to lift the barrier off the floor. There were multiple holes in the plastic barrier which were covered with tape. Air was blowing from the construction area into the Central Sterile Processing area. Directly adjacent to the plastic barrier were a number of stainless steel wire carts containing sterile supplies and surgical packs, waiting to be transported to the operating room for patient use. It was also observed there were several "crash carts" stored directly adjacent to the plastic barrier. When the carts, crash carts and stainless steel storage carts were wiped with a clean white cloth, there was a visible black residue on the cloth, indicating possible contamination of sterile supplies on the carts.

During an interview with EPI, CNO, DPS and the SPS, on 5/17/16, at 9:30 AM, they were not aware of the amount of dust and dirt recovered. The EPI then provided a hospital policy and procedure titled "Infection Control Construction Permit". This permit, dated 3/22/16 and posted next to the construction site, indicated the construction would be completed within two weeks and would be "small scale, short duration" and at "Medium Risk". The purpose of the construction was to repair and fix the leak in the area from a flooding incident occurred in September last year. The work would involve major demolition and new construction of the area and would affect all patients seeking treatment at the hospital (also called Class IV construction requiring the most protective measures to minimize risk of hospital acquired infections). The Permit posted next to the construction was marked as a "Class 2." However, review of the hospital "Infection Control Risk Assessment Tool" revealed Sterile Processing Department was in Group 4, the highest risk area for infection control.

During interviews with the EPI and the SPS, on 5/17/16, at 9:45 AM, the hospital staff stated the daily inspections had not been performed because of the expected short duration of the construction. A state of Immediate Jeopardy was declared because the dust and dirt contamination could not be consistent with sterile surgical supplies and equipment.

Based on observation, interview, and record review, the hospital failed to have an effective Quality Assurance and Performance Improvement (QAPI) program in place to ensure information regarding the infection control risk of the construction area in the sterile processing department was collected daily and reviewed periodically. This failure resulted in the hospital's inability to ensure safe care to its patients.

Findings:

During a tour of the Central Processing Department of the hospital with the Project Manager for Construction (PM), the Epidemiologist (EPI), the Sterile Processing Supervisor (SPS), the Chief Nursing Officer (CNO), and the Director of Preoperative Services (DPS), on 5/17/2016, at 9 AM, a large, 42 feet long by approximately 12 feet high, plastic barrier was observed to the right of the entrance. This area used to house an autoclave (equipment used to sterilize surgical equipment). The PM stated the autoclave was removed from use sometime ago and the room became vacant and unusable. The PM explained during a flooding incident last September, the leak caused some damage to the ceiling tiles and the pipes. The plastic barrier was used to ensure the dust and debris could not escape to the Sterile Processing area. The plastic barrier was found to have multiple tears and not secured to the floor. There was consistent air blowing from the construction area outward to the Sterile Processing Department.

Also observed was an "Infection Control Construction Permit," dated 3/22/16, posted next to the construction area and signed by the EPI, Manager, Plant Operations (MPO), and the Chief Operating Officer/Acting Quality/Risk Management Director COO. The Permit indicated the construction would take about two weeks to complete. The plastic barrier remained in place through 5/16/16. Neither the EPI nor the PM was able to provide an updated Infection Control Construction Permit.

During interviews with the EPI and the SPS, on 5/17/16, at 9:45 AM, both stated the daily inspections had not been done because he (EPI) assumed the work would be done in two weeks. The EPI was not aware of the construction inside the contained area was still ongoing.

The hospital's policy and procedure on "Construction/Renovation and Infection Control", reviewed on 10/2015, under "ENFORCEMENT", read: "A. The Project/Construction Manager and contractor are responsible for daily compliance monitoring per the Daily Monitoring Form... C. The Project/Construction Manager will maintain records of such compliance rounds." The hospital could not provide any completed "Daily Monitoring Form: or other documentation of monitoring of this construction area from 3/22/16 through 5/16/16.



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During an observation and concurrent interview with the PM, on 5/16/16, at 9:41 AM, in the Central Sterile Processing and Supply area, a large, approximately 42 feet long by 12 feet high, plastic barrier was observed. The hospital document titled "Infection Control Construction Permit, Attachment B" (ICCP), dated 3/22/16, was posted at the zippered doorway. The ICCP indicated this was a "Group II, Type B" project with an estimated duration of two weeks. The area under the zippered doorway was not sealed to the floor and the plastic wall panels were observed to be bulging outward toward the sterile supplies. Upon entering the construction area, it was observed that several holes in the plastic barrier had been previously repaired with tape while additional holes had not been repaired. A high-efficiency particulate arresting (HEPA) filter (removes particulates from the air) was blowing towards the sterile supply area. The obsolete sterilizer, which had been observed during the 3/2016 survey, had been removed however the exterior wall had not been closed and sealed. The interior wall was stripped down to the studs. The damaged ceiling had been removed, exposing the basement infrastructure including steam pipes. The cement block drains for the steam lines were covered in plastic, and steam was observed to be rising from the major drain and water dripping into a secondary drain. The plastic covering the cement blocks were wet with condensation. Upon removing the plastic, a brownish scorch type discoloration was noted. The PM stated the plastic had been placed by the company, which had removed the damaged wallboard and ceiling tiles, around 3/11/16. No explanation was provided for why the plastic was still in place. She also stated the opening for the sterilizer remained because of the possibility that a new sterilizer would be ordered and that the project had been stalled as they researched various sterilizers.

The hospital policy and procedure titled "Infection Control Risk Assessment Tool (ICRA), Attachment A," dated 10/27/15, indicated under Definition of construction Activity Types "Type C:" Work that generates a moderate to high level of dust or requires demolition or removal of any fixed building components or assemblies. Includes...removal of ceiling tiles, new wall construction; minor ductwork or electrical work above ceiling...any activity that cannot be completed within a single shift and also indicated under Definition of Infection Control Risk Groups, "Group 4 Highest [Risk]:" Sterile Processing."

During a record review and concurrent interview with the EPI, on 5/16/16, at 11:59 AM, he stated the project was completed and the paperwork had been filed. It (the removal of the obsolete sterilizer) only took three days. No explanation of why the plastic barrier remained up or why the ceiling and walls remained open was provided. The EPI was unable to provide any documentation of monitoring of the construction area and stated it was just for three days. The EPI stated the Infection Control Coordinator (ICC) was responsible to monitor the construction area (including barrier integrity) while the project was ongoing. He then restated that the project was completed in three days.

During an interview with the Director of Facilities/Consultant (DFC), on 5/16/16, at 12:04 PM, he stated the project "is not complete." The EPI then stated the ICRA had not been updated.

During an interview with the PM, on 5/17/16, at 8:50 AM, she stated the ICRA was for the entire project and included the abatement (demolition and clean-up) and the removal of the obsolete sterilizer.

The hospital policy and procedure titled Construction/Renovation and Infection Control, dated 10/27/15, indicated under "REPORTING" B. The Project/Construction Manager shall keep members of the Infection Control Risk Assessment Team apprised as to the progress of construction."

Based on observations, interviews, and review of documents, the hospital's governing body failed to assume the legal responsibility to ensure its quality assurance and performance improvement program addressed the condition of the construction area in the Sterile Processing Department as cited in the original re-certification survey.

This failure had the potential to affect the sterility of ready-for-patient-use surgical supplies and sterile surgical packs stored in the Sterile Processing Department and unsafe care to all patients in the hospital.

Findings:

During a tour of the central processing area of the hospital, on 5/17/2016, at 9 AM, with the Project Manager for Construction (PM), the Epidemiologist (EPI), the Sterile Processing Supervisor (SPS), the Chief Nursing Officer (CNO), and the Director of Preoperative Services (DPS), the condition of the old autoclave (equipment used to sterilize surgical tools) area was inspected. It was observed that sterile supplies were stored on numerous stainless steel storage carts and several crash carts outside the construction area. A plastic barrier covered the outside of the construction area to contain the dust and debris caused by the construction. There were several tears in the plastic barrier held together by construction tape. The barrier was not secured to the floor by paper tape and left enough space for air to blow from the construction area to the Sterile Processing Department. The PM stated the duration of the construction should have been only two weeks, starting 3/22/16.

The policy and procedure on "Construction/Renovation and Infection Control" was reviewed on 5/17/16. The hospital's policy and procedure indicated the PM and contractor were responsible for "daily compliance monitoring per Daily Monitoring Form."

During an observation on 5/17/16, at 9:30 PM, when the carts, crash carts and stainless steel storage carts were wiped with a clean white cloth, there was a visible black residue on the cloth, indicating possible contamination of sterile supplies on the carts. The EPI, CNO, the DPS and the SPS were not aware of the amount of dust and dirt generated by the construction.

During interviews with the EPI and the SPS, on 5/17/16, at 9:45 AM, both stated the daily inspections had not been performed because of the expected short duration of the construction.

Based on observation, interview, and record review, the hospital failed to have a care plan (provide direction for the type of care the patient needs) for three (2, 3,and 4) of 30 sampled patients. This failure had the potential for staff not knowing how to provide care for their patients.

Findings:

During an observation on 5/16/16, at 2:55 PM, in the Intensive Care Unit (ICU), there was a sign outside the room of Patient 2 indicating Contact Isolation.

During an interview with Registered Nurse (RN) 12, on 5/16/16, at 3 PM, she stated Patient 2 was on Contact Isolation for C. Diff (Clostridium difficile- is a bacterial infection that causes mild to life-threatening forms of diarrhea).

During a review of the Electronic Medical Record (EMR) for Patient 2, with the Director of Telemetry (DT) she was unable to locate a care plan for Patient 2 being on Isolation. The DT stated "There isn't one."

During an observation on 5/16/16, at 3:35 PM, there was a sign outside of Patient 3's room indicating Droplet and Contact Isolation.

During a review of the EMR for Patient 3, with the DT she was unable to locate a care plan for Patient 3 being on Isolation. The DT stated "There should be one..."

During a observation on 5/17/16, at 12:42 PM, there was a sign outside of Patient 4's room indicating Contact Precautions.

During a review of the EMR for Patient 4, the was no care plan found for Isolation. The DT verified the findings.

Based on interview and record review the hospital failed to:

1. Have a discharge plan for one (3) of 30 sampled patients.

2. Have a discharge plan in a timely manner for one (4) of 30 sampled patients.

This failure had the potential to have patients needs go unmet.

Findings:

1. During an interview with the Director of Telemetry (DT), on 5/17/16, at 4:25 PM, she reviewed the electronic medical record (EMR) for Patient 3. Patient 3 was admitted on 5/13/16 at 5:20 PM. The DT was unable to find a discharge planning assessment.

2. During an interview with the DT, on 5/17/16, at 4:45 PM, she reviewed the EMR for Patient 4. Patient 4 was admitted on 5/6/16, and initial discharge planning assessment was done on 5/12/16 (six days later). The DT verified the findings.

The hospital policy and procedure titled "Discharge Planning" review date 1/2015, indicated "B. Each patient will have a Discharge Planning Assessment completed by Case Management Staff (Case Manager, Social Worker, and/or Discharge Planner) within 24 to 48 hours upon admission..." I. Discharge Planning is an on-going process in which patients are re-assessed... Re-assessment will be done every 4th day from their last assessment."