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At the time of the re-visit on March 10 and 11, 2015, this deficiency had not been corrected.

Based on document review and staff interview, the governing body did not ensure:

a. the hospital was constructed, arranged and maintained for patient safety and to appropriately provide for the needs of the patients; See Tag A-0700.

b. surgical services were provided in accordance with acceptable standards of practice and enforce the use of proper surgical attire for staff; See Tag A-0940.

c. the infection control preventionist (ICP) developed and maintained a comprehensive ongoing infection control program that reviews hospital practices and infections/communicable diseases, analyzes data on these practices and infections, develops qualitative plans of actions to and provides follow-up to ensure corrective actions are appropriate, working and sustained ensuring a safe and sanitary environment. See Tag A-0749.

Based on hospital document review and staff interviews, the hospital failed to ensure that all departments reported to the Quality Assessment Performance Improvement (QAPI) program. The hospital failed to ensure issues identified were analyzed and reported to the governing body.

Findings:
1. On the afternoon of March 11, 2015, surveyor AA asked staff H if all program services reported to QAPI. Staff H told surveyor AA not all hospital departments were reporting to quality.

2. On the afternoon of March 10, 2015, surveyors reviewed QAPI meeting minutes. There was no documentation on patient safety, medication errors and adverse events. Departments that reported to QAPI did not have documentation that data was analyzed for each department.

3. On the afternoon of March 10, 2015, surveyor AA asked the Chief Nursing Officer (CNO) if she could find documented evidence on patient safety, medication errors and adverse events in the quality meeting minutes. The CNO told surveyor AA that a medication safety committee had been formed and the information would be in a medication safety committee binder.

4. On the afternoon of March 10, 2015, surveyor AA asked the CNO why the medication safety committee was formed? The CNO told surveyor AA that there were possible drug diversion issues on four different occasions.

5. On the afternoon of March 10,2015, surveyors reviewed QAPI meeting minutes, Medical Staff meeting minutes, and Governing Body meeting minutes. There was no documentation that the possible drug diversions were analyzed and reviewed through QAPI, Medical Staff, and Governing Body.

6. On the afternoon of March 10, 2015, surveyors reviewed incident reports from 2014 through current. There was one documented incident report regarding potential drug diversion.

7. On the afternoon of March 10, 2015, surveyor AA asked the CNO for all incident reports from 2014 through current. The CNO told surveyor AA that she provided all incident reports. The CNO told surveyor AA that she did not fill out incident reports on the other situations as she was too busy and did not have enough hours in the day to fill out the reports.

8. On the morning of March 10, 2015, surveyors requested the hospital's Incident reporting policy and procedure. Staff E provided a document titled, "Occurrence/Incident Reporting" policy and procedure to surveyor AA.

9. The Occurrence/Incident Reporting policy and procedure documented, "...Any happening out of the ordinary...will be reported through completion of occurrence/incident report..." and "...The reported data from incident reports will be used to monitor, evaluate, and improve the quality and safety of hospital services..."

At the time of the revisit on March 10 and 11, 2015, this deficiency was not corrected.

Based on observation, document review and staff interview, it was determined the hospital failed to ensure the facility was constructed, arranged and maintained for patient safety and to appropriately provide for the needs of the patients.

Findings:

A tour of the surgical department(OR) was conducted on the afternoon of March 10, 2015 with Staff G and on the afternoon of March 11, 2015 with Staff P.

The OR did not have adequate space for the scope of services provided. All the required features for the surgery department were not provided.

There were no clean and dirty utility rooms. The department did not have an anesthesia workroom. The operating rooms shared a janitor's closet with the recovery room. There was no biohazard waste collection room within the surgery department. There were no rooms designated for clean and dirty linen storage.

A sterile core area was observed in the OR. This was an open area between the the OR suites and the decontamination room. Sterile surgery supplies and instruments were stored in the sterile core. The OR did not contain a sterile supply room.

The autoclave in the sterile core was not sealed appropriately and air circulated under and around it. The mechanical parts and plumbing were exposed to the sterile core.

There was no handwashing sink in the decontamination room. This was observed by Staff P during the tour.

The pass through doors nd shelving in the decontamination area were made of a non-porous material.

Traffic and workflow processes in and through the OR did not minimize the potential for cross-contamination.

Acoustic ceiling tiles were observed throughout the semi-restricted area of the OR. Some of the tiles were "bowed", stained and cracked.

Review of OR monitoring logs, documented negative air flow in the instrument wrap room.

At the time of the revisit on March 10 and 11, 2015, this deficiency was not corrected.

Based on review of hospital documents, surveyor observations, and staff interviews, the hospital failed to ensure the infection control preventionist (ICP) developed and maintained a comprehensive ongoing infection control program that reviews hospital practices and infections/communicable diseases, analyzes data on these practices and infections, develops qualitative plans of actions to and provides follow-up to ensure corrective actions are appropriate, working and sustained ensuring a safe and sanitary environment.

Findings:

Review of the Infection Control Committee (ICC) meeting minutes did not reflect staff immunization status and employee health were reviewed as part of the infection control program. Meeting minutes did not demonstrate analysis of employee, contract staff, physician and allied health immunizations, illness and infections to ensure infections and diseases were not transmitted between patients and staff.

On the afternoon of March 11, 2015, Staff C was asked if the disinfectants used in the hospital had been reviewed and approved by the ICP, infection control committee and the medical staff. Staff C stated no.
Review of the credential files for Staff O and J contained a Tuberculosis (TB) screening last completed in 2012. Staff A and C were asked for a current TB for the above mentioned employees. None was provided.


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On the morning of March 10, 2015, surveyors requested a list of approved disinfectants used throughout the hospital. The ICP (Infection Control Practitioner) told surveyor AA that the medical staff and governing body had approved the use of bleach and bleach wipes hospital wide therefore there was no disinfectant list.

On the afternoon of March 11, 2015, the ICP informed surveyor AA that she did not realize all solutions used throughout the facility needed to be on a list. The ICP also told surveyor AA that she thought by having everyone in every department use bleach wipes or bleach solution, it would cut down on the confusion of wet times and what product killed what organism.

On the afternoon of March 10, 2015, surveyors toured the surgery department. Surveyor AA observed Phenolic Disinfectant and Cleaning product (18L), neutral Quat Disinfectant cleaning product (23L), PDI Sani-Wipe Bleach (orange top), bleach and water solution, WD-40, and Lysol Nutra air sanitizing spray in the surgery department.

On the morning of March 11, 2015, surveyor AA observed a housekeeping cart that contained the following cleaners: Windex, Lysol toilet bowl cleaner, Febreze deodorizing spray, and TB Quat spray.

On the morning of March 11, 2015, surveyor AA asked staff R what cleaners did she use to clean the facility. Staff R told surveyor AA that all the housekeeping carts should have the same cleaning products on them. Staff R name Windex, Lysol toilet bowl cleaner, Febreze deodorizing spray and TB Quat spray.

Based on document review and staff interviews, the Chief Executive Officer, Medical Staff, and Chief Nursing Officer failed to ensure infection control issues were identified and addressed by the Infection Control Practitioner (ICP) and Quality Assessment Performance Improvement (QAPI) program.

Findings:
1. On the morning of March 10, 2015, surveyors requested infection control meeting minutes, medical staff meeting minutes, and QAPI meeting minutes.

2. Surveyor AA reviewed infection control meeting minutes, medical staff meeting minutes, and QAPI minutes. There was documented evidence of infection control data being collected but there was no documentation of an action plan of the data or analysis of the data.

3. On the afternoon of March 11, 2015, surveyor AA asked the ICP how often she observes personnel in the surgery department looking for compliance with surgical attire. The ICP told surveyor AA that she does environmental rounding twice a year. The ICP was not aware that 3 (Staff G, S, and BB) of 4 staff members were not compliant with the hospital's surgical attire policy and procedure.

4. Hospital leadership did not ensure that trash, dirty linens,and biomedical was immediately removed from the surgery department. On the afternoon of March 10, 2015, was verified by Staff G while touring the operating room.

5. On the afternoon of March 11, 2015, the ICP verified that there was no documented evidence of an action plan or analysis of infection control data.

At the time of the re-visit on March 10 and 11, 2015, this deficiency was not corrected.

Based on observation and staff interview, it was determined the hospital failed to ensure the surgical services are provided in accordance with acceptable standards of practice and enforce the use of proper surgical attire for staff.

Findings:

A tour of the surgical department(OR) was conducted on the afternoon of March 10, 2015 with Staff G and on the afternoon of March 11, 2015 with Staff P.

Acoustic ceiling tile was noted in the ante room of the endoscopy suite and throughout the semi-restricted corridor of the OR. This was confirmed by Staff P.

In OR #2 a staff members lunch container, a corrugated box, magazines and office supplies such as paper clips and a wooden ruler were observed on a cart. This was also observed by Staff G during the tour.

Plastic bags containing dirty trash and linens were observed in the procedure room and lying on the floor a semi-restricted corridor of the OR. This was also observed by Staff G during the tour.

A sterile core area was observed in the OR. This was an open area between the the OR suites and the decontamination area.

An autoclave, sterile supplies and four scrub sinks were all located in this area.

The sterile supplies were stored within the splash zone. The sterile supplies were also immediately adjacent to the autoclave and were repeatedly exposed to the heat and steam from the autoclave.

The shelves used to store the sterile packages were rusty.

See Tag A-0700.




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On the afternoon of March 10, 2015, surveyors requested a tour of the surgical department. Staff G accompanied surveyors to the surgical department.

Staff G met surveyors in the administration conference room and took surveyors to the women's surgical department locker room.

Surveyors changed to appropriate surgical attire per the hospital policy and AORN (Association of periOperative Registered Nurses) recommended standards of practice guidelines.

Staff G did not change her scrubs upon reentry to the surgical department (restricted and semi-restricted areas) and gave the surveyors a tour of the entire surgical department.

Surveyors observed several plastic bins tightly packed with peel packages of sterilized equipment. The peel packages were smashed and bent in order to fit in the plastic bins. The integrity of the peel packages could not be maintained based on the hospital's current practice of storage.

On the afternoon of March 11, 2015, surveyor AA observed staff BB lying on the main hallway floor with her head on the floor and her right arm inside a vending machine. Surveyor AA observed staff BB wiggling and rolling on the floor until she obtained her candy bar. Surveyor AA observed staff BB with a disposable blue bouffant cap on her head, scrub top and scrub pants, a zip up hooded sweatshirt tied around her waist, white tennis shoes, employee badge clipped onto the outside of the scrub top pocket, and a Snickers candy bar. Staff BB identified herself to surveyor AA as a RN (registered nurse) who was currently working in the OR as a circulating nurse.

On the afternoon of March 11, 2015, surveyor AA observed staff BB entering the semi-restricted area of the surgical department.

Surveyor AA asked staff BB when she would change her scrubs and disposable hat. Staff BB told surveyor AA that she would change her scrubs if they were visibly soiled or when she was going home for the day. Staff BB told surveyor AA that she would take her disposable bouffant cap off when leaving at the end of the day.

Staff BB acknowledged and verified she was on the hospital hallway floor trying to get her candy bar that was stuck in the vending machine but would not change her scrubs or hat upon re-entry to the surgical department.

Surveyor AA observed staff BB opening her Snickers candy bar and eating it without performing hand hygiene while re-entering the surgical department.

Staff BB told surveyor AA that as long as she remained in the hospital she did not change her scrubs upon reentry to the surgical department. Staff BB also informed surveyor AA that she did not wear shoe covers in the surgical department because her tennis shoes are dedicated to the hospital. Staff BB verified that the zipped hooded sweatshirt tied around her waist is what she wore in the OR during surgical cases as the circulating nurse.

The hospital's surgical attire policy documented, "...All personnel entering semi-restricted and restricted areas of the surgical suite shall be in operating room attire...OR attire which is soiled or wet shall be changed...The surgical hat or hood is to be clean...Shoe covers are worn and are to be change whenever torn, soiled, or wet..." and "...Staff who is not "scrubbing in" shall wear long sleeved jackets..."

AORN (page 51) 2013 Standards and Recommended Practices documented, "...surgical attire should be donned daily...before entry or reentry into the semirestricted and restricted areas..."

Surveyor AA asked staff BB if she was aware of the hospital's surgical attire policy. Staff BB said, "I am supposed to."

On the afternoon of March 11, 2015, surveyor AA observed staff S transporting a patient by wheel chair out of the surgical department. Staff S was wearing blue disposable leg and shoe covers.

Staff S reentered the surgical department while wearing the same blue disposable leg and shoe covers when he left the surgical department transporting a patient by wheel chair. Staff S also reentered the surgical department without changing his scrubs.

On the afternoon of March 11, 2015, staff S told surveyor AA that he would change his scrubs and shoe and leg covers before entering the restricted area of the surgical department.

Staff G, S, and BB did not follow the hospital's surgical attire policy and procedure which is based on the AORN Perioperative Standards and Recommended Practices for Surgical Attire.

The morning of March 10, 2015, surveyor AA requested the hospital's surgical attire policy for the OR (Operating Room). A policy titled, "Surgical Attire" was provided by Staff E.