HospitalInspections.org

Based on observation of the decontamination room, and interview the facility failed to ensure a sanitary environment in the decontamination room this deficient practice had the likelihood to cause harm to facility patients.

Findings:
A tour of the decontam room was conducted on 06/25/19 beginning at 2:40 p.m.

a. Staff #10 was asked to show the area for the drain for sterilizer #3. A metal panel was leaned up against a wall at the back of the left side of the room. A rolling cart was positioned in front of the panel. The manager moved the panel which was not secured to the wall. Observation revealed deteriorating wood, deteriorating sheetrock, rusty pipes, pieces of insulation and debris on the floor.


b. Staff # 10 was asked to show the area for the drain for sterilizer #2. A metal panel held in place by a fastener on each side and a lip at the top of the panel. A rolling cart was positioned in front of the panel. The manager opened the panel. Observation revealed deteriorating sheetrock, rusty pipes, pieces of insulation, and debris on the floor including green fabric.

c. A hopper sink to the front right of the room could not be flushed, the left faucet handle had green corrosion around it and water dripping in a steady stream, the faucet was dripping constantly, and the ceramic bowl had greenish brown debris in the bowl and around the edges.

d. The metal door below the scope cleaner next to the hopper sink was covered with dried drippings.

e. A rolling cart on the front left side of the room was covered with dusty debris, dried drippings and there was rust on the bottom shelf.

Observations revealed 2 metal case carts outside of OR#2 and OR#3 with rust on all 4 wheels of both carts.

Staff #10 was interviewed on 6/25/19 and according to him:All metal pans are wiped out when they are returned after a case.
Any metal pans that go into the room with a patient in the room are sent thru the washer sterilizer.

Based on observation of the decontamination room, and interview the facility failed to ensure a sanitary environment in the decontamination room this deficient practice had the likelihood to cause harm to facility patients.


Observation of the washer sterilizer in use on 6/25/19 at that time revealed the presence of a metal tray in the washer sterilizer.

1:05 p.m. - Observation in the presence of staff member #10 revealed:

A metal tray used for holding a Shake N Bake instrument set with dusty and sticky tannish debris in the bottom. Staff member #10 confirmed the observations.

A metal tray used for holding a Red & Grey lami set with tannish debris and black flecks in the bottom that could be wiped out with a Sani cloth. staff member #10 confirmed the observations.

Observation in the presence staff member #10 revealed:

A metal tray that held a minor set was opened after having been sterilized by staff member #10. The minor set was lifted out of the tray. Tannish sticky debris with black and blue flecks was observed in the bottom of the tray that could be wiped up with a Sani cloth.


Staff #10 was interviewed on 6/25/19 and according to him:All metal pans are wiped out when they are returned after a case.
Any metal pans that go into the room with a patient in the room are sent thru the washer sterilizer.