HospitalInspections.org

Based on observation, interview, and document review the facility failed to ensure biohazards were labeled, hand hygiene was performed consistently, and the Infection Control Program surveillance activities included surgical site infections, resulting in the potential for ongoing acquisition of healthcare associated infections and transmission of infectious agents among patients and staff.

See specific findings in A-749: failure to provide a sanitary environment and maintain an active program for the prevention, control, and investigation of infections.

Based on observation, interview and document review the facility failed to provide a clean environment and maintain an Infection Control Program that included surveillance activities of surgical site infections resulting in the potential for the spread of infectious disease. Findings include:

On 01/30/2017 at 1030 during tour of the fifth floor Intensive Care Units, the dirty utility room #5228 was observed for the "Soiled Medical Equipment/Instrument Pre-Cleaning and Transport Process." The dirty utility room had a shelf next to the hopper (modified toilet for the flushing of waste) that contained an open yellow 2 bin container labeled for "dirty medical equipment." A wrapped pair of hemostats was in one of the two bins. There were no gloves or eye protection available for staff use. The secure red Biohazard bin was not able to be located for the transport of the dirty equipment. Additionally the plastic bags to put the dirty equipment into had to be obtained from the clean supply room across the hall, the bag was not puncture resistant, and it did not have the Biohazard warning on the outside. Staff C the director of Quality stated "Karmanos purchases the secure red bins for the transport of dirty equipment to the central processing area, but the transporter forgets to bring them back."

On 1/30/2017 at approximately 1045 tour of the fifth floor Post Operative Intensive Care Unit was conducted. Upon observation of the "Soiled Medical Equipment/Instrument Pre-Cleaning and Transport Process" in the room designated as "Soiled Utility" it was noted that the dirty equipment processing area did not have a hopper for the disposal of waste. "Maxzyme Foam" (an enzymatic cleaner) was available for the cleaning of dirty instruments. A secure red bin for transporting to central processing was not present and there were no plastic biohazard bags. Staff I was asked were the biohazard bags were located for staff to put the dirty equipment into, He stated "let me find out." He returned with a plastic patient belonging bag that was not puncture resistant or labeled as a biohazard.

On 01/31/2017 at 1300 observation on the first floor Wentz unit was conducted. Staff 0 was observed cleaning an examination room after a procedure. She was wearing gloves to remove all linen and then do the initial cleaning of the soiled speculum (medical equipment used for the examination.) She placed the speculum in a secure bin labeled with biohazard warning symbols, she then carried the container to the decontamination room without changing her gloves or performing hand hygiene. She place the sealed container on the counter for further processing and returned to the exam room and then changed her gloves without performing hand hygiene. When this was brought to her attention she removed her gloves and performed hand hygiene.

The tour continued to the unit's decontamination room at approximately 1320 at which time Staff P was observed completing the cleaning and preparation for equipment to be returned to the central processing area. Staff P completed the cleaning of the speculum and was also cleaning a laryngoscope from a previous procedure. He failed to perform hand hygiene between glove changes between the two pieces of equipment. When queried, he stated "I can't get the new gloves on if my hands are wet."

On 01/30/2017 at 1300 the policy titled "Soiled Medical Equipment/Instrument Pre-Cleaning and Transport Process" #IC 116 dated 09/23/2016 on page 1 of 1 "...C...segregate in a puncture resistant container...K. If container or tray is not of solid construction, place in plastic bag and attach biohazard sticker...N. Remove personal protective equipment (PPE) and perform hand hygiene."

On 01/30/2017 at 1500 the Infection Control Committee Minutes were reviewed from 4/1/2016 to present. The minutes dated 6/8/2016 on page 1 of 6 under 2...e. "No Surgical Site Infections (SSI) identified with colon or hysterectomy surgeries during the first quarter." The minutes dated 9/14/2016 on page 2 of 7 under 2...e. "One SSI with a colon surgery and 5 SSI's with other types of surgeries were identified in the second quarter. Harper will no longer be reporting Karmanos Cancer Center (KCC) SSI's to the Centers for Disease Control as they consider KCC patients to be outpatients. Centers for Medicaid/Medicare does not require SSI's from outpatients to be reported."

On 01/31/2017 at 1230 Staff E the Infection Control Officer was interviewed. She reported that she did go to Harper hospital infection committee meetings and reports back to the KCC infection control committee. She was asked if she had done an analysis on the SSI's that had been reported to her in September. She stated "No." She went on to say that she did not realize that she had to take over the surveillance that included infection detection, data collection, analysis, monitoring and evaluation of preventative interventions now that Harper is no longer reporting KCC infections."

On 01/31/2017 at 1400 review of the policy titled "Surveillance Methodology" #IC159 dated revised 08/22/2016 revealed on page 1 of 2 "4...Karmanos Infection Control Department will identify hospital associated infections..."