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Based on observation and interview the facility failed to ensure the environment of the facility was devoid of high dusting, failed to ensure the containment of refrigerated medications were kept in clean storage, and failed to ensure staff, students, and visitors were monitored for appropriate use of personal protective equipment resulting in the potential for the spread of infectious disease among all patients receiving services at the facility. Findings include:

On 1/30/2017 at 1030 a tour was conducted on the sixth floor. On 1/30/2017 at approximately 1045 on the six west unit a group of medical students (7) were observed entering a patient room. Four of seven medical students were observed donning personal protective equipment (PPE) without tying gowns. On 1/30/2017 at 1040 an interview was conducted with the Quality Compliance Risk manager and the clinical nurse manager of the six west unit, at which time it was asked who was responsible for teaching medical students the appropriate use of PPE. The Quality Compliance Risk manager and the clinical nurse manager were unable to answer who was responsible for teaching students the use of PPE. A medical student was then queried as to where the use of PPE was taught prior to students coming to the facility for clinical rotation. The medical student responded that use of PPE was taught during orientation. When asked if there was any testing as to the student's knowledge or understanding of use of PPE the medical student responded "no." On 1/30/2017 at approximately 1050 the Quality Compliance Risk manager and the clinical nurse manager were then asked, is there any monitoring put in place to ensure staff, students, and visitors are wearing PPE as needed and when necessary. Both responded that they were unsure if the use of PPE was being monitored.

On 1/30/2017 at approximately 1015 during tour of the sixth floor areas both units were checked for high dusting. High dust accumulation was found on all items that were hanging in the corridors on signage and artwork hung in patient care hallways and hallways connecting six east and six west units. On 1/30/2017 at approximately 1020 the Quality Compliance Risk manager was asked who was responsible for ensuring items were dusted on a regular basis for high dust. The Quality Compliance Risk manager responded it is the responsibility of environmental services department to dust items.

On 1/30/2017 at approximately 1100 a tour was conducted of the fifth floor east unit. The shelved area in the public hallway was found to have a collapsed activity walker, a bottle of baby shampoo, and paperclips stored. The fifth floor east clinical nurse manager was asked if the items should be stored in an open area in the public hallway and if the items were clean or used and dirty. The fifth floor east clinical nurse manager was unable to ensure the items were clean, or used and dirty. She responded "I think they are clean. I will remove them."

On 1/30/2017 at approximately 1115 during a tour of the medication room on the east unit of the fifth floor it was observed a high amount of dust had accumulated on the medication dispensing unit (PYXIS) machine, on the window sills, and on shelving. The medication refrigerator was observed to have dust located inside on the shelving and heavily inside the door. Ice accumulation was also observed. The clinical nurse manager of the east unit of the fifth floor was then asked who would be responsible for ensuring the medication refrigerator was devoid of dust and ice. The clinical nurse manager was unable to verify who was responsible for keeping the medication refrigerator devoid of dust and ice. The clinical nurse manager was then asked if environmental services was allowed entry to the medication room for housekeeping and dust duties. The clinical nurse responded "yes".

On 1/30/2017 at approximately 1125 on the fifth floor west unit a patient care assistant was observed in a patient room at a computer wearing PPE. The PPE gown was not tied and the face mask was below the patient care assistant's mouth while she was conducting a phone conversation. The clinical nurse unit manager for the fifth floor west unit was then asked if the PPE was being worn correctly by the patient care assistant. The clinical nurse unit manager replied "no".

On 1/30/2017 at approximately 1125 it was observed in the public hallway areas connecting the units on five west and five east that objects hanging on the walls had high dust accumulation. The Quality Compliance Risk manager was asked if environmental services was responsible for dusting and housekeeping needs on the floor. The Quality Compliance Risk manager replied "yes".

On 1/30/2017 at approximately 1130 during a tour of the pediatric intensive care unit (PICU) a nurse was observed wearing personal protective equipment at which time the mask was not secured or placed above the nose but below the nose. The PICU clinical nurse manager was interviewed on 1/30/2017 at approximately 1135 and asked if wearing a mask below the nose was the appropriate placement for a mask. The PICU manager replied "no".

On 1/31/2017 at 0725 in the public corridor located between the reception desk and the parking garage entrance an employee was observed wearing personal protective equipment (PPE), a yellow isolation gown, as the employee was exiting the facility. An employee entering the facility was asked if they were aware of who that individual was and she replied "it is a nurse from the ER (emergency room department) I'm pretty sure ...But for sure it is a nurse because she has on navy blue scrubs."

On 1/31/2017 at 1000 an interview was conducted with the facility epidemiology nurse staff FF and the infection preventionist nurse staff GG. Both staff FF and staff GG were asked how often staff members, students, volunteers, and visitors were monitored for proper use of personal protective equipment (PPE). Staff FF responded "we used to do monitoring on a monthly basis then it was quarterly but the monitoring has not been as much as of lately." When asked to explain how long monitoring has taken place for the use of PPE staff FF responded "we haven't monitored (PPE use) since we lost an employee in our department a year ago." Staff GG then added "we are just like every other department ...spread too thin and not enough help." Staff FF identified her employment status as one full time equivalent and staff GG identified her employment status as one half full time equivalent. Staff FF and staff GG stated they were responsible for all infection control program monitoring for all departments of the facility including inpatient and outpatient areas. This facility is licensed for 228 beds and has 102 offsite locations.

Based on observation, interview, and record review the facility failed to maintain well-organized surgical services and failed to provide and maintain appropriate sterile surgical instrumentation in sufficient numbers to meet needs of surgical services provided in accordance with acceptable standards of practice, resulting in delays in surgical procedures, patients being exposed to anesthesia for longer than necessary, increased flash sterilization and the increased potential for infection and negative patient outcomes for all surgical patients serviced by the facility. Findings include:

A0941 - failure to maintain well-organized surgical services and failed to provide and maintain appropriate sterile surgical instrumentation in sufficient numbers to meet needs of surgical services provided in accordance with acceptable standards of practice

Based on observation interview and record review the facility failed to maintain well-organized surgical services and failed to provide and maintain appropriate sterile surgical instrumentation in sufficient numbers to meet needs of surgical services provided in accordance with acceptable standards of practice, resulting in delays in surgical procedures, patients being exposed to anesthesia for longer than necessary, increased flash sterilization and the increased potential for infection and negative patient outcomes for all surgical patients serviced by the facility. Findings include:

During an observation in operating room (OR) number 12 on 1/30/17 beginning at 1045 Surgical Technician (ST) Staff L was observed inspecting a surgical instrument tray on a separate stand from the sterile field for a surgical procedure scheduled at 1030. Staff L noted a discoloration on one of the instruments and notified the OR manager Staff K who was in the room. Staff K observed the instrument and agreed there was discoloration. Staff K then performed a Resi test (test to detect biological matter/bioburden) on the instrument. The test was negative. A second tray was brought in for inspection and found to have three instruments with discoloration. All three were tested for bioburden with the Resi test and were negative. The trays were removed from the OR. A third set was brought in and inspected and used for the surgical case. Staff L stated all three trays were basic surgical trays. The patient was brought into the room at 1105.

At the time of the above observations Staff K stated any instruments found to be discolored or have possible contamination are tested with the Resi test, removed from the OR and the set number, set name, builder number, date assembled and name of the builder are documented on the instrument count sheet and CSP (Central Sterile Processing) OR liaisons are notified and shown the Resi test tube to verify results. Then the entire surgical tray is returned to CSP for reprocessing. The OR manager or OR Director then enters the information into the Midas system (incident tracking system). If any instruments test positive the CSP Supervisor or Manager is notified. Staff K was observed following the above process with the CSP OR liaison at 1125.

On 1/30/17 at 1025 the OR Director Staff M verified the above information related to the follow up procedure for possible contaminated surgical trays. Staff M stated in the past two to three weeks there has been a large increase in the number of instruments that have had discoloration and staff suspected it may be rust. Staff M stated that the facility has been investigating possible causes and one thought was it was the enzyme spray being used post-op on the instruments which were then covered with a wet towel while awaiting processing in CSP. Staff M stated "We are starting a trial today with a new product and eliminating the wet towel cover. I have been verbally educating staff on the new product 1:1 today. We have had delays in starting surgical cases related to the compromised instrument trays." At 1345 Staff M confirmed all staff had been educated on the new enzymatic surgical instrument product.

On 1/30/17 at 1100 Medical Staff N was queried with regards to concerns with surgical instruments. Staff N stated, "We are still having problems with instruments missing from sets and compromised instruments with rust on them. Cases have been delayed, and the operating room staff are checking everything carefully."

On 1/30/17 at 1135 Operating Room Staff O stated that there are still a lot of issues with the facility's surgical instruments, and frequently on the weekends. Within the last month there were several cases where no instruments were available to do the surgeries. One case was an emergency bowel resection. No basic sets were available. The surgeon was going to transfer the patient to another hospital, but we were able to put together a set using instruments from other trays. So he ended up being able to do the case here. On another day we had an emergency liver transplant to do. The liver transplant set is supposed to be in the department. When it gets used it is an immediate turn around tray, meaning it is sterilized in CSP right away and sent back to the Operating Room. The tray was found down in CSP. The set had been used a week before and not been brought back to the Operating Room. There were several occasions when the heart team opened sets, sometimes as many as three in one day, where either rust or bioburden was found on the instruments. During a neuro-shunt placement case last weekend I found a straight hemostat with a piece of material that fell out when I opened the clamp. The material tested positive for blood. I told the surgeon about the instrument and broke down my set up, and then reset up for the case. The patient was in the room being prepped at the time. It was about a 10 minute delay and then the case went on. Also, last weekend we didn't have supplies. There were no drapes, towels or saline solution. We ended up getting these supplies from Harper Hospital so we could do our cases."

On 1/30/17 at 1400 Staff DD a ST was observed in OR number 6 packing and pre-treating instrument trays with the new enzymatic product following a surgical procedure. All surgical instruments appeared to be free of large amounts of biological matter and were thoroughly coated with the new enzymatic spray and covered with a dry disposable blue towel. Staff DD stated when setting up the OR for a surgical case this morning she had opened two surgical trays which contained instruments with discoloration. She stated they tested negative for biologic matter and were removed from the OR. Staff DD stated the third surgical tray was not compromised and was used for the surgical case.

On 1/30/17 at 1450 an observation with Staff K of the soiled utility room revealed two instrument carts that were completely filled with used surgical trays (4-6 trays in each cart with additional soiled basins and smaller trays/instruments placed on top of surgical trays). Other OR staff were entering the room with soiled surgical trays and looking for places in the carts to put them. Staff K was asked how often the carts of dirty instruments were picked up and Staff K stated, "About every 30 to 60 minutes." At 1453 three staff who identified themselves as CSP Instrument Associates (IA) s arrived to pick up carts. IA Staff W retrieved an additional cart from the clean utility room for additional trays being dropped off by OR staff. Staff W stated "My job is to process instrument trays in CSP. I had to stop processing a tray because I got a call to come and pick up the carts. We do not have enough staff at all to get everything done. We often are stopped from doing our job of processing trays to pick up carts. There are only two people assigned to pick up and deliver carts for all the hospitals and units. One staff is assigned to (name of hospital) and one is to cover the other four hospitals. It is non-stop back and forth for eight hours a day." After approximately eight minutes all of the carts were ready for transport. Each of the three IA's pushed one cart to CSP through the tunnel system connecting all the hospitals followed by two surveyors which took approximately nine minutes.

Following arrival at CSP at 1510 Staff X a CSP Coordinator stated that "Nine staff called in today and CSP is working short staffed." Staff X stated that it happens often. When queried as to how many staff should be on duty today, Staff X stated "15-18 and we are working with only six staff today in processing." Observations of the racks for storage of instruments dedicated to (name of hospital) revealed a rack approximately five feet tall full of instruments trays. Staff X stated they were clean and just waiting to be sterilized. Staff X stated "we are backed up." She then opened a surgical basket marked with one of the other hospital's names and stated "Why is this in here? This is a basic back table set and should have been processed and returned immediately." Staff X stated that on a weekend recently (approximately two weeks ago) she happened to find a liver transplant tray sitting on the processing cart (clean but not sterilized). She stated "It is an automatic turnover tray and thank God I saw it and processed it because they had an emergent transplant come in that day. New staff do not know what instrument trays need immediate turnover."

On 1/31/17 at 1035 and 1045 Medical Staff R and Staff Q respectively, were interviewed and queried regarding concerns with surgical instruments. Both Staff R and Q stated they had never had any concerns with contamination form bioburden on surgical instruments. Both staff verbalized that lost instruments resulting in incomplete surgical sets was the biggest concern. Staff R stated there is a problem with instruments not being returned from CSP. Staff R stated in the past few weeks there has been a problem with discoloration thought to be rust on instruments, and with trays missing instruments which has caused multiple sets of surgical instruments to be opened in the OR before a sterile or complete set is found which can be used. This results in the surgical tray that is needed for the surgery to be unavailable, which then results in a delay of surgery. "Once recently a case was delayed two hours. Last week after three trays were opened and not useable, I had to put together a surgical set from several different sets." Staff Q stated "The OR nurses and technicians are very good at inspecting the instruments and I feel assured that what we use is sterile." Staff Q stated his surgery today was delayed for 45-50 minutes while staff inspected multiple surgical trays before a complete set was found.

On 1/30/17 at 1030 and 1435, on 1/31/17 at 1210 and on 2/1/17 at 1320, respectively, interviews were conducted with Staff M the OR Director. During an inspection of the sub-sterile area of the Operating Room a rack was identified that was used for storage of 50 surgical trays labeled as incomplete or missing instrumentation. Staff M stated, "These trays are stored here so we can complete them with items that have been ordered, and use them for backup sterile instruments when a tray is discovered incomplete or compromised during a surgical procedure." Staff M stated "I have ordered new instruments to complete the trays, and sent the new completed trays to CSP and they have come back with different instruments missing." She stated two of the back table trays (standard surgical instrument sets) have missing instruments and we only have a total of four." Two surgical trays and one sternal saw were removed from the rack to be opened and inspected. The two surgical trays were found to be intact without any signs of rust or residue. When the sternal saw was opened Staff M pointed out an area of residue on the saw in the space where the blade would be loaded. Staff M confirmed the saw was considered contaminated and could not be used during a surgical procedure. Staff M stated "Often trays are not processed and returned from CSP timely. We have three intraocular trays and last week we needed one and all three were still in CSP. They were sent down seven days earlier. . . We send a daily form to CSP at 1500 which shows how many surgical trays we have available and how many we need for the scheduled surgical cases the next day. More than a couple times weekly we do not receive the needed surgical trays the next morning on the case carts (carts requested from CSP for logged cases each day). Every day we open surgical sets and find incomplete trays, missing instrumentation and instruments compromised with rust causing delays in surgical cases and canceled surgeries." She stated "My goal is to complete the trays that are out of circulation. We had a concern today with a tray that was not available from CSP, we borrowed one from the Troy facility. We opened the tray here in the OR unit, insured it was clean and complete, then sent it to CSP for processing and it came back missing a trocar (main instrument). Recently one of the surgeons needed to do a case on an in-patient and both surgical trays he needed were incomplete from CSP. The physician rescheduled the surgery for the next day. When I do have concerns with instrument loss or trays not delivered I call management in CSP. We are attempting to account for sets and track them. We have held surgical cases (delayed) to ensure we have complete surgical sets. When the problems started the patients were often in the room during the delay, now we do not take the patient into the room until we are sure we have a surgical set we can use. Some of our cases require an extensive prep of the patient and this requires the patient to be in the room. If we are delayed for 40-45 minutes or longer we file a Midas report."

On 1/31/17 during an observation at 1425 at the end of a surgical procedure in Operating Room (OR) number 6 it was observed that sterile instrument trays were being stored on the shelf beneath the Scrub Technician's back table. The shelf contained two Book Walter retractor surgical trays, one Adult Laparotomy surgical tray, and one blue wrapped Dermatome surgical instrument. The shelf also contained two adult size gel positioning rolls, two previously opened cloth towels, two sterile glove packages, and two containers of foam instrument spray. When staff T was asked why the sterile instruments were under her back table, and why these instruments would be needed for a six- week old undergoing a Laparoscopic abdominal surgery she stated the following. "I should have put those trays away. I put away the trays for general surgery. Those trays must have been from Friday. The trays shouldn't be there." Staff M and Staff U confirmed the trays should not have been placed there and should have been removed when the room was wiped down before any case was done in OR number 6. Staff T, M and U verified with surveyor that the trays were considered contaminated and would be sent for reprocessing.

The facility provided a copy of an algorithm titled "Peri-operative Process for instrument Issues Identified in the OR" revised 1/25/17 that was reviewed on 2/1/17 at 1410. The algorithm documented the following chain for reporting: OR staff--OR Director-- (Medical Center Chief Nursing Officer (CNO) -- CSP Leader--Risk Management and included an escalation check list.

On 1/31/17 at 1130 manufacturer's insert and policy related to Resi test were requested. The following information was received: "Manufacturer's "Indications for Use", "Verify Resi Test Indicator" and Sample Product Procedure titled "Residual detection testing for protein using Verify Resi-Test", which documented use for detection of residual protein (biological matter/bioburden) on medical devices after cleaning.

On 1/31/17 at 1300 Medical Staff P was interviewed and queried regarding concerns with instrumentation. Staff P stated the number one concern is with missing/wrong instrumentation in surgical sets. He said for the last few weeks there has been concerns with rust on instruments almost daily. Often having to tear down the OR room and set it up again. The CEO (Chief Executive Officer) and OR Director are working very hard, but not getting the funds needed. Staff P stated "We hear all the time that CSP is short staffed and there seems to be no accountability by anyone." He stated it has been a problem since sterilization was moved from (name of hospital) and centralized. "The problems are getting worse not better. . . We also have a concern with OR staff being cut. In the past we had dedicated staff who knew the complexities of neuro surgeries and now staff do not. We spend time training new staff during complex surgeries. We discuss it every month in our surgical staff meeting, it consumes most of our meeting time." He stated "I will no longer do cases at the hospital on the weekends unless the patient can't wait because of the concerns with instrument availability, rust on instruments and lack of supplies like shoe covers, drains and shunts among other supplies." Staff P added "All of us want to do the right thing. We have spent all of our professional careers here and we have tried to work with the parent company. We make do with what is available and they count on that."

On 1/31/17 at 1350 with Staff S a CSP supervisor, an observation of the dry erase board in CSP documented "Six call ins today, two staff on medical, 2 staff on vacation, short 10 people." Staff S stated "We do not have enough staff, I had to work in decontamination today to cover." She stated "We have a lot of new staff and they are paired with an experienced person for 90 days, but it isn't enough."

On 2/1/17 at 1000 Medical Staff CC (related to the complaint) was queried regarding the concern with bioburden being found on a surgical instrument. He stated "That was the first time I had ever found anything that was even possibly bioburden on an instrument." He verbalized he was not informed that it was positively bioburden. He stated after the compromised instrument was found he reported it to risk management on the same day (verified by the Midas report). Staff CC stated recently there has been many concerns with rust on instruments and concerns with missing or incomplete surgical sets. He stated there have been many concerns with CSP.

On 2/1/17 at 1400 an undated form titled "(name of hospital) Trended Surgical Cases" documented a total of 812 in-patient and out-patient surgery case preformed in Oct. 2016, 812 surgery cases performed in Nov. 2016 and 819 surgery cases performed in Dec. 2016. January numbers were not available on the form.

The facility Midas report tracking system for incidents from 11/1/2016 to 1/27/2017 were reviewed on 2/1/17 from 1100 to 1400 to confirm the above observations and interviews. The following information was documented:

Five surgical instrument trays were found with contamination which tested or was identified as positive for bioburden. On 11/22/16 a Laryngoscope (an instrument used to view or insert a tube in the throat) was found with debris and tested positive for bioburden. On 12/19/16 a surgical set in the OR had instrumentation that tested positive for bioburden. On 12/23/16 bioburden was found on an instrument while the patient was in the OR room (incident related to the complaint). On 1/16/17 possible bioburden was observed on suction equipment, when flushed, debris were noted floating in basin and on the suction tip, which was documented as "bioburden." On 1/21/17 debris were noted to fall out of a straight hemostat (a type of clamp) in the OR while the patient was in the room.

Approximately 24 surgical instrument trays were found with contamination which tested negative for bioburden. Of these cases four patients were present in the OR during the surgical instrument inspections. Thirteen of these incidents resulted in delays of surgical cases from a few minutes to two hours (five delays were one hour or longer). During a delay on 1/13/17 it was documented that the patient was unnecessarily exposed to anesthesia for 1 ½ hours longer related to being in the OR during which time three basic surgical sets were opened and found to be contaminated and the fourth set being unavailable related to being used earlier in the day.

The reports documented multiple incidents of surgical trays not being returned timely from CSP or trays missing from case carts or additional trays needed which were located in CSP un-sterile (often related to multiple trays being opened and found contaminated). Dates included (12/19/16, 1/8/17, 1/9/17, 1/12/17, 1/18/17, 1/20/17, and on 1/23/17 (tray was noted to be in CSP for seven days), among other dates prior to December 19, 2016.

The reports documented multiple incidents of trays with missing or incorrect instruments found. Often requiring flash sterilization to be used or alternate tray types being substituted. This resulted in delays of surgical cases at times (12/28/16 delayed start, 1/12/17 delayed 43 minutes, 1/16/17 delayed start, two delays were documented on 1/26/17 one 40 minute delay, and one 38 minute delay) among multiple other dates with no indication of whether delays occurred.

The report documented that on 1/17/17 CSP was called multiple times related to soiled instrument carts needing to be picked up.

On 2/1/17 at approximately 1300 review of QAPI and Governing Board meeting minutes dated September 2016 - present revealed the facility had been aware of the issue of missing instrumentation and the staffing challenges at CSP since September 2016 (following onsite survey at sister hospital). When queried the Chief Medical Officer stated, "We have purchased additional instruments and we talk about it (staffing issues) but the union contracts confine us to what we can do."

On 2/1/17 at 1440 CSP policies related to scheduled timing of soiled instrument cart pick-up and delivery, surgical instrument wait times in decontamination, surgical instrument turn-around times in processing and sterilization were requested but not provided. The policies provided did not contain the above noted information.




29955

On 1/31/2017 at approximately 1130 a review of the flash sterilization report (Immediate Use Steam Sterilization - IUSS) was conducted. According to the IUSS report for the facility IUSS rates were as follows: September 2016 8.0%, October 2016 6.05%, November 2016 2.30%, and December 2016 4.30%. The target set for IUSS for the facility was identified as 3%. The report further reflected reasons for flash sterilization (IUSS). Categories for reason description included: Item Dropped, One of a kind set / instrument, Contaminated: Holes in wrap, Item missing / Incorrect, Specific item not available and needed for, Back to Back Cases, No other sterilization alternative, Contaminated: Other, and Vendor set / Loaner instrument.

On 1/31/2017 an interview was conducted with staff M the Administrative Director of Surgical Services. Staff M was queried as to the categories for use of immediate use steam sterilization (IUSS). Staff M was asked to describe the terminology or meaning of back to back cases. Staff M replied "Back to back case is when a surgery takes place where there is no other instruments available for the same type of surgery for the very next case." Staff M was then asked is that the same as one of a kind set/instrument. Staff M stated "yes." Staff M then shared that there are periods of time where certain instruments become missing although there are ample instruments of that kind. Staff M stated as an example that mouth gags used for tonsil and adenoid surgeries have been missing. Staff M stated that although there are currently 5 to 6 mouth gag sets that only one is currently accounted for at the present time (1/31/2017). Staff M further stated "there is no reason that can be identified why instruments come up missing ...and it seems to be a period of time that certain instruments come up missing ...for example it was CV (cardiovascular) retractors for a period of weeks." Staff M then was asked to explain if communication has taken place with central sterile processing to collaboratively address the issues. Staff M stated "it is a daily discussion."

On 1/30/2017 at 1300 a request was made for staffing grids for the central sterile processing (CSP) department. On 1/30/2017 at 1430 staff DD the operations manager assistant director provided the staffing grid for CSP. Staff DD was asked how many employees called in for 1/30/2017. Staff DD stated "so far today we have had 13 employees call in (absences)." Staff DD was then asked if employee turnover was an issue for the CSP department. Staff DD responded "Employee turnover is not the issue in our department. Employee absenteeism is our greatest hurdle. We are constantly trying to fill holes. We currently have 20 of 87 employees on FML(A) (Family Medical Leave Act). We are held hostage by employee absenteeism, because of union contracts we are required to offer all of the union employees of the CSP department overtime prior to taking any other action to fill shifts where employees have called in for the shift." Staff DD further stated "We have to pull employees from the processing of the instruments to be transporters (staff who go to all hospitals and units to pick up or deliver instrument carts) and shift employees around to try and make things work. We then have supervisors filling spots and working longer hours." Staff DD was then asked how often working short or on a skeletal staff was occurring. Staff DD answered "daily, every shift." When asked how long this has been occurring in the CSP department staff DD stated "since I have been at this location for two and half to three months."

On 1/30/2017 at 1530 the central processing department's attendance record for the month of January 2017 was requested. On 2/1/2017 at approximately 1100 an attendance record for the month of January 2017 was provided. According to the attendance record from 1/1/2017 through 1/31/2017 there were 146 absences of 1564 scheduled shifts for an average of 9.3% absenteeism percentage over thirty-one days. The absenteeism percentage ranged from 0% (1/7/2017 and 1/28/2017) to 26% (1/30/2107).

On 1/31/2017 at 1400 an interview was conducted with Staff Y the Director of the Central Sterile Processing (CSP) department, Staff Z the educator of CSP, and Staff AA the quality manager of CSP. The director was asked what he considered a reasonable expectation for the processing of surgical instrumentation would be for the facility. The Director responded "in an ideal situation instruments would be processed and trays available in a twenty-four hour turn around." The Director was then asked what the turnaround rate for instrumentation is currently. The Director responded "honestly, 72 hours." The Director further stated "right now, at this current time, I can honestly say I can only guarantee that expedited (high priority) items and the trays for the first and second surgeries for the day are guaranteed." When asked if adequate staff were available for processing of instrumentation and delivery of case carts the director responded "not really. We have a constant struggle with absenteeism which started at the beginning of the year. Staff were upset that overtime had been cut. We (CSP) have seen an increase in call-ins (absenteeism) since the beginning of January (2017)." When asked if employees from different departments could be pulled to help address the absenteeism in the department the director responded "no, per union contracts we are bound to calling all employees within the department to fill any available hours." The director was then asked how the department adjusts when there is call-ins for the shifts. The director responded "We (CSP) have to pull instrument associates to fill in if it is a transporter position, but we do not have anyone to pull if an instrument associate calls in. The instrument associates have a certification and extensive education. We cannot put just anyone in those positions if they do not have the training and certification."