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Based on observation, and interview, the hospital failed to provide secure storage for drugs and biologicals to prevent access by unauthorized individuals in the geriatric mental health unit.
Findings:
During the tour of the mental health unit's locked medication area, the surveyor found the medications cart was locked, however, the third row of drawers in that cart did not lock. Patient medications were in the unlocked drawer.
The geriatric mental health unit manager demonstrated the drawers were not locked by opening them while the remainder of the cart was locked.
This condition granted unauthorized access, by any staff, due to staff bathroom entrance located in the same area as the cart.

Based on observation, and interview, it was determined the hospital failed to provide a safe environment that was free from known hazards.
Findings:
During the tour of the mental health unit, it was found that grab bars in two of two shower rooms, one of one tub room, and one of one toilet room were not constructed to be ligature-free. Geriatric mental health unit manager acknowledged that the grab bars were not ligature free design.

Based on observations, staff interview, and document review, the hospital failed to develop an active program for the prevention and control of infections and communicable diseases.

Findings:
1. Prevention

The hospital's infection control documents, including the Tuberculosis (TB) risk assessment and the infection risk assessment, were reviewed.
~The TB risk assessment report was dated 2015.
~On 09/20/2016, during an interview, Staff B stated the TB risk assessment had not been conducted for 2016.
~The 2016 infection control risk assessment had been scored. Staff B stated the infection control risk assessment had not been analyzed and no plan of action had been developed.

2. Control
The hospital's infection control reports documented the hospital had rendered care to three patients with C-difficile (C-Diff.) infections (an intestinal bacteria responsible for causing infectious diarrhea) in 2016.
~On 09/20/2016, the competency file of Staff Q, a housekeeper, was reviewed. The file did not contain evidence that the staff was trained on the appropriate methods for disinfecting the environment of patients isolated for C-Diff.
~The hospital policies titled, "Cleaning Isolation Patient Occupied" and "Cleaning Isolation Patient Room Discharged" were reviewed. Neither policies defined the requirements for the disinfection of the environment patients with known C-Diff infections. The hospital policy titled ,"Isolation Control" documented, "C. Diff...Contact [standard] (Clean with bleach product."

Surgery
On 09/20/2016, the surgical unit, including the room labeled "Central Sterile", was toured.
The Central Sterile area contained a steam sterilizer and a vat of Cidex OPA (a high level disinfectant) both of which require negative air ventilation. This area's air test and balance report confirmed the room had a negative air flow.
~ Within the Central Sterile area was a large covered stainless steel rack which contained multiple shelves of wrapped surgical instruments. (Wrapped sterile instruments require positive air flow requirements, and designated air exchanges, and humidity requirements to minimize the risk instrument contamination.)
~During an interview, Staff I stated the wrapped items were left on the rack for twenty four hours and then put in a storage cabinet in one of the operating suites. Staff I stated the rack was used for "drying" the instruments; however, the Chief Nursing Officer stated the packs were not very wet when they were removed from the sterilizer. (Generally, wrapped surgical instrument dry within 30 minutes to two hours of being removed from a steam sterilizer).
~On 09/20/2016, the OR Director and Staff I both stated wrapped supplies on the rack could not be stored in the designated Sterile Storage room, because there was "no room" on the shelves. The air test and balance report for the Sterile Storage room confirmed positive air pressure and correct humidity levels. ~A hospital policy titled, "Function of Central Sterile Dept" was reviewed. The policy documented, "Sterile Supplies: Proper storage and handling of sterile supplies shall be maintained to prevent contamination".

Sleep Lab
On 09/21/2016, the Sleep Lab was toured.
The Sleep Lab had two sleeping areas (resembling hotel rooms). During an interview, Staff E stated the Staff AA had performed two sleep studies (which measures breathing patterns as patients sleep) the night prior to the tour and was unavailable. ~In both of the sleeping rooms, the beds were unmade and the bedspreads had been folded and placed on a chair within each room. In an interview, Staff E stated the two patient bedrooms had not been cleaned yet. Staff E stated bedspreads were removed prior to the patients getting in bed, but were not removed from the room. Staff E could not be verify that the patient had not used/contaminated the bedspread during the night. ~During the tour in sleeping room #1, the closet contained linens and various cleaning supplies. The linen was not covered or wrapped to protect it from contamination.
The Sleep lab's front door opened into a room that contained both an office and pasteurization and aeration equipment. The pasturization/ aeration equipment was used to disinfect continuous positive airway pressure (CPAP) accessories. The aeration chamber contained multiple CPAP circuit hoses. ~The facility policy titled, "Cleaning & Maintenance of Equipment and Reusable Sensors 8/16" documented, "Masks and hoses...soak in Pasteurize per manufacture recommendation..." ~The surveyor requested manufacturer's information for use for the CPAP mask and circuitry. No manufacturer's information was provided for the CPAP circuitry used. (This information would be used to verify the products used by the facility were manufactured as reusable for multiple patients, and to ascertain the proper guidelines for disinfection.) ~The decontamination/disinfection process for the respiratory equipment was not confined into a dedicated reprocessing space which was free from traffic.
Physical Therapy
On 09/21/2016, the surveyors toured the Physical Therapy Area. ~During an interview, Staff MM stated the area did not have the manufacturer's instruction for use for the Hydrocollator (a heating unit for hot packs). Staff MM stated no log was kept to record temperature and disinfection interval. ~Staff MM stated the Hydrocollator had been cleaned monthly in the past; however, due to the staff's heavy workload and the lack of a floor drain, that equipment was currently being disinfected quarterly.
The surveyors observed two cannisters of disinfectant wipes on a shelf by the Hydrocollator. ~Staff MM stated the wipes were used for disinfecting the surfaces of the equipment. Both cannisters of wipes expired in 2014.
Dietary
On 09/21/2016, the surveyors toured the Dietary Department.
Multiple refrigerations contained food that was opened and/or had been removed from the original container, such as, opened bacon, plastic wrapped cheese, all food and dressing items from the salad bar, bowl of chicken or tuna salad covered with plastic wrap, and macaroni salad covered with plastic. ~On 09/20/2016, during an interview, the Dietary Manager confirmed the opened/undated food, and stated the food should be dated when opened.
On 09/20/2016, the surveyor requested the temperature logs for the kitchen food. No food temperature logs were provided during the survey. ~During an interview, the Dietary Manager stated that the staff had not been testing food temperatures. ~The hospital policy titled, "Proper tray assembly" documented, "Temperature of food is taken prior to tray service to ensure hot foods are hot and cold foods are cold."
Emergency Department
On 09/21/2016, the surveyors toured the Emergency Department.
As a new patient was being brought into exam room three, the surveyor observed a suture removal kit on a counter that was used on a prior patient. ~Staff L discarded the kit as it was identified by the suveyor, and failed to disinfect the counter.
Shelves of supplies were observed located within the splash zone of the scrub station in the Trauma Room. The supplies consisted of clean and sterile supplies such as foley catheters, sterile cups, and urinals.

Based on staff interview and document review, the hospital failed to ensure surgical fire risk reduction measures were implemented within the facility's sugical suites.

Findings:
On 09/20/2016, during the surgical unit tour, oxygen, alcohol [fuel], and cautery [heat] were observed in the surgical suites, and their presence increased the risk of surgical fires.

During an interview, the Surgical Director stated the surgical staff did not perform a surgical fire risk assessment prior to the surgical procedures.

Four of four personnel files of surgical staff were reviewed, and contained no training for surgical fires mitigation.

During an interview, the Quality Director stated the facility had no policy for surgical fire risk assessment.