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Based on interview and record review, the GB failed to ensure the contracted services for the central SPD cart washer was evaluated for quality of service provided. This failure increased the risk of poor health and safety outcomes to the patients.

Findings:

On 9/2719 at 1500 hours, the Facility Director stated the central SPD cart washer was maintained by the contracted vendor from the cart washer manufacturer.

Review of the Preventive Maintenance Services Agreement under County's Quality Assurance Plan dated 6/17/03, showed the County or its agents will evaluate the contractor's performance under this agreement on not less than an annual basis. Such evaluation will include assessing the contractor's compliance with all contract terms and performance standards. Contractor deficiencies which the director determines are severe or continuing and that may place performance of the agreement in jeopardy if not corrected will be reported to County's Board of supervisors. The report will include improvement/corrective action measures taken by the Director and contractor. If improvement does not occur consistent with the corrective action measures, County may terminate Agreement or impose other penalties as specified in Agreement.

On 9/30/19, the performance evaluation of the contracted service providing services for the central SPD's cart washer was requested.

On 10/1/19 at 0916 hours, the Director of Accreditation stated the hospital evaluated the financial aspect of the contracted service but not the performance of the contracted service related to the central SPD cart washer.

Based on observation, interview, and record review, the hospital failed to ensure the protective cover of the hot steam pipe was not maintained. This created the increased risk of poor equipment performance impacting the safety of patients and staff.

Findings:

On 9/30/19 at 1110 hours, a tour of the main OR was conducted with SPD Supervisor 2. In the clean room of the OR Core B sterile processing and storage area, the white pipe cover was observed with cracks and dark brown to black burned mark. The concurrent interview with Central Services Technician 3, he stated the pipe was the hot steam pipe of the autoclave that was currently being used for sterilization instrument tray. Central Services Technician 3 was not aware of when or how the black mark appeared.

Based on observation, interview and record review, the hospital failed to ensure the hospital's P&P and standards of practice were implemented as evidenced by:

1. Failure to ensure the flow of traffic for contaminated supplies and equipments was separated from the clean or sterile supplies and equipment in the OR hallway as per the hospital's P&P.

2. Failure to ensure the instrument cleaning process was maintained to prevent the potential of cross contamination.

3. Failure to ensure the decontamination room was maintained in clean and sanitary manner.

4. Failure to ensure the ice machine in the surgical restricted area was cleaned and sanitized.

5. Failure to ensure the hot water was available and the water temperature was monitored properly when diluting the enzymatic solution as per the hospital's P&P.

The failures created an unsafe patient care environment and risk of spread of the infection to the patients.

Findings:

1. Review of the hospital's P&P titled Decontamination Work Area Flow Pattern in Central Service dated 1/11 showed the decontamination processes are achieved either mechanically or manually. Soiled or contaminated supplies and equipment must be kept separated from the clean and sterilized supplies and equipment.

Review of the hospital's P&P titled Sterilization: Cleaning & Decontamination Process dated 4/16 showed central service instrument cleaning and decontamination occurs in the decontamination room. This area is separated from locations where clean activities occur.

Review of the hospital's P&P titled Sterilization: Cleaning & Decontamination of Instruments (General Policies & Procedures) dated 1/16 showed the purpose of this P&P is to define the general P&Ps related to cleaning and decontamination of instruments prior to sterilization. Transport containers must be labeled to indicate bioharzardous content. Carts, reusable biobins, or any other transport container must be decontaminated after each use.

According to the AORN's Guidelines, 2019 edition, Guidelines for Preoperative Practice: Instrument Cleaning, physical separation of decontamination areas from areas where clean items are handled minimizes the risk of cross-contamination. Cross-contamination can result when soiled items are placed in close proximity to clean items or area placed on surfaces upon which clean items are later placed. Droplets and aerosols created during cleaning of soiled instruments can cause cross-contamination of any nearby clean items or surfaces.

On 9/30/19 at 1100 hours, a tour of the surgical area, including the decontamination and SPD areas of Cores A and B and OR hallways was conducted with the OR Manager and SPD Supervisor 2. The corridor outside of ORs 16 and 17 was observed to have the large and uncovered case cart with clean instruments that were ready for processing. The SPD staff was observed cleaning the dirty carts next to the clean instrument case cart. The OR Manager and SPD Supervisor 2 verified the finding.


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2. On 9/30/19 at 1110 hours, a tour of the surgical area was conducted with the OR Manager. In the OR Core A decontamination room, the ultrasonic cleanser was observed on the right side of the room. Sinks 1 and 2 were observed on the left side of the room. Further down from Sinks 1 and 2 at the end of the room, the pass-through window was observed opening to other side of the room which was the clean area of the SPD.

Central Service Technician 1 stated she started to clean the used instruments with the water and detergent by using Sinks 1 and 2. After cleaning the used instruments in Sinks 1 and 2, the used instruments were transferred to the ultrasonic cleaner. After the used instruments were washed by the ultrasonic cleaner, the washed or cleaned instruments were transferred to the opened pass-through window to the clean area for packing. However, Central Service Technician 1 had to walk pass Sinks 1 and 2 area in order to transfer the washed or cleaned instruments to the pass-through window.

Central Service Technician 1 stated it would be risk for the cross contamination when the cleaned instruments were transported passing through the sinks area where the used instruments were.

The OR Manager confirmed the finding.

3. Review of the hospital's P&P titled Surgical Suite-In-Depth & Terminal Clean revised 8/18 showed the procedure for daily terminal cleaning includes to move all equipment, wet scrub floor, clean baseboards, and clean all wheels and casters before moving back items into the cleaned location.

On 9/30/19 at 1110 hours, during the tour of OR Cores A and B, the decontamination room was observed being used by the Central Services Technicians. The floor mat underneath the sink had accumulated dusts, debris, and small piece of sticky label.

During the concurrent interview with Central Service Technician 1, Central Service Technician 1 stated the EVS staff was responsible for the daily terminal cleaning in this area.

On 10/1/19 at 1230 hours, an interview was conducted with the ADON. The EVS terminal cleaning record was requested for review. The ADON stated she confirmed with the EVS Director that the EVS staff performed the daily terminal cleaning for the main OR, including the OR and decontamination room; however, there was no documented evidence showing when those rooms were last terminally cleaned.

4. On 9/30/19 at 1110 hours, a tour of OR Core B was conducted with the OR Manager. The ice machine was observed with a label "Clinical Use." Water was observed dripping from the ice dispenser. Greenish liquid matters was observed on the drain of the ice machine.

During the concurrent interview with the OR Manager, the OR Manager stated this ice machine had not been used for three years.

5. Review of the hospital's P&P titled Care, Cleaning, and Tracking of Medical Equipment dated 8/18 showed the following:

* Pre-cleaning is the cleaning of contaminated instruments with the water and enzymatic product to remove the gross organic material and prevent the organic material left on the instruments from drying.

* The pre-cleaning of surgical instruments algorithm showed to ensure the water temperature is at 90-120 degrees Fahrenheit when mixing the Prolystica (enzymatic solution) solution.

On 9/30/19 at 1110 hours, a tour of the main OR was conducted with the OR Manager. The following was identified:

a. In the OR Core A decontamination room, an interview was conducted with Central Service Technician 1. Central Service Technician 1 stated she used the cold water when mixing the Prolystica solution. Central Service Technician 1 stated she was aware of the use of warm water or the requirement for the water temperature when mixing the Prolystica solution. However, there was no heated water available in the the OR Core A decontamination room and there was no thermometer available to check the water temperature.

b. In the OR Core B decontamination room, an interview was conducted with Central Service Technicians 2 and 3. The Central Service Technicians stated they mixed the hot and cold water when diluting the Prolystica. However, they did not monitor the water temperature because there was no thermometer available.

Based on observation, interview, and record review, the hospital failed to establish and identify the designated SPD areas in the OR department as per the AORN's guidelines. This failure had the potential of the spread of infection throughout the hospital.

Findings:

According to the AORN's Guidelines, 2019 edition, Guidelines for Preoperative Practice: Design and Maintenance, the health care organization should establish an interdisciplinary team with authority and responsibility to provide oversight of surgical suite construction or renovation projects. An interdisciplinary team can provide expertise on functional design, the functional needs of the users, infection prevention, sustainability, and regulatory requirements from a variety of viewpoints.

On 9/30/19 at 1100 hours, a tour of the surgical area, including the decontamination and SPD areas of Cores A and B, OR hallways, ORs 5, 16, and 23 was conducted with the OR Manager and SPD Supervisor 2. SPD Supervisor 2 stated ORs 5, 16, and 23 were designated for SPD services.

The corridor outside of ORs 16 and 17 was observed to have the large and uncovered case cart with clean instruments that were ready for processing. The SPD staff was observed cleaning the dirty carts next to the clean instrument case carts. The surgical case was being performed in OR 5. There was no signage posted to identify ORs 5, 16, and 23, and the corridor as the designated SPD area.

The OR Manager and SPD Supervisor 2 verified the finding. The OR Manager verified the OR schedule showed the surgical cases were scheduled to be performed in ORs 5, 16, and 23 today while these ORs were designated to be used by the SPD staff. The OR Manager stated no signage was posted to identify the SPD area was relocated to ORs 5, 16, and 23, and the corridor.