The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

Based on observation of staff infection control practices, interview of hospital staff, review of related policies and procedures specific to the disposal of medical waste and the use of protective personal equipment used during patient care, it was determined that the staff failed to consistently follow and implement infections control measures important in the prevention of potential hospital acquired infections.
The findings were:
1) During an onsite survey of 8/18/2015, that included observation of a surgical port-a-cath removal in the interventional radiology unit, it was observed at 0839 that the Interventional Radiologist failed to utilize any type of eye shield during the surgical procedure, which included removal of a catheter from a vein, and irrigation/suctioning of the surgical site. Eye protection for potential splash or spray of blood during the removal of a medical appliance such as the Port-a-cath serves as a protective barrier against a potential exposure to staff.

2) On 8/18/2015 at approximately 0820 AM, an observation of a dirty utility room on the Interventional Radiology unit revealed a Stericycle corrugated paper box in approximate dimensions of 2.5 ' high by 18 " wide, by 15 " deep. The box was lined with a medical waste red bag. The floor of the box was observed to be fully packed by 1000 cc glass thoracentesis bottles, standing side-to-side without any packing between the bottles, which were filled with various body fluids and , if broken during transport, could potentially result in leakage of bodily fluids.

Interview with the manager of the unit while in the dirty utility room revealed that when thoracentesis fluids were obtained, the bottles were placed into the box until the box was approximately full of the thoracentesis bottles. It is estimated that in order for the box to be full, the glass bottles would have to be stacked 3 bottles high with each full bottle weighing approximately 2.2 lbs (the weight on one liter of water). No additional packing for protection of breakage was noted. A surveyor statement to the Manager that the disposal system appeared problematic for keeping the bottles from breakage, elicited the Manager statement that this was a possibility. The Manager stated that Environmental Services would dispose of the box when full. Interview with the EVS Manager on 8/19/15 at approximately 10AM revealed that the boxes containing thoracentesis fluids are moved via hand truck.

A " Packaging Procedure " poster for the corrugated boxes and plastic bins was noted on the wall outside the dirty utility room. The poster stated in part, " Sharp materials ("sharps" ) must be placed in a puncture-resistant container designed for "sharps" waste. "Sharps" include needles, syringes, broken glass ... " The placement of glass thoracentesis bottles in multiple levels inside a medical waste red bag that is inside a corrugated paper box did not appear to represent a puncture-resistant container in the event of glass breakage. Additionally, in the case of glass breakage, no similar caution was noted on the poster for the box to be leak-proof. It is a standard that liquid medical wastes be in leak-proof container It is also noted that in order to secure the bottom of the box, a packing-type tape is used which might not be strong enough to hold the weight of a corrugated paper box 3/4 filled with glass bottles full of body fluids.

A hospital policy "Boxed Regulated Medical Waste Removal and Transportation" (effective 01/2015) reveals in part, that an " Approved regulated waste container" is used to handle and transport infectious waste in compliance with all Federal, State, and local guidelines. The policy does not differentiate between the types of boxes transporting glass containing liquid medical waste. The policy stated that the containers must not be more than 3/4 full of weigh more than 50 lbs.

Based on these observations and information, it does not appear to be a safe process for the disposal of liquid medical waste where glass bottles stacked side-to-side, and in layers inside a non-leak proof corrugated paper box lined with a medical waste bag.

3) Observation during a colonoscopy of Staff #F. on the morning 8/18/15 revealed that staff #F. did not clean the access port on the intravenous (IV) tubing prior to accessing the port with a syringe of IV medication. This finding was confirmed by the operating room manager who was in attendance during the observation of this procedure.

Failure of all staff to properly clean IV ports with alcohol prior to accessing with medication places the patient at risk for infection.

4) During the same observation of the colonoscopy on the morning of 8/18/15, it was observed that the circulating nurse failed to don appropriate personal protective equipment (PPE) when entering the procedure field while the colonoscopy was in progress. PPE is any protective gear used to protect staff against potential exposure to infectious agents. The circulating nurse was originally seated away from the procedure field. This nurse was wearing surgical scrub attire, hair covering, and shoe coverings. During the procedure, the circulating nurse walked away from her documenting desk and stood next to the physician while performing the colonoscopy. This finding was brought to the attention of the operating room (OR) manager who was also present during the observation of the procedure. The manager immediately requested that the nurse step away from the procedure to place a face mask with an eye shield. The nurse complied with that request.

On the morning of 8/19/15 an interview took place by the surveyor with the Director of Surgical Services and the OR Manager (who was present during the procedure). The Director provided a copy of the '2015 Edition Guidelines for Perioperative Practice'. Also provided was a copy of 'Guidelines for safety in the gastrointestinal endoscopy unit'. The Director stated that the policy of wearing PPE for endoscopy procedures is based on these two guidelines and that it was not the policy for the staff to wear PPE if the staff are not "directly engaged in the endoscopy procedure".

The Centers for Disease Control(CDC) recommends that any "activity" in which potential contact of blood or bodily fluids is anticipated a gown to protect skin and clothing should be worn as well as eye protection for potential splash or spray of blood, respiratory secretions, or other body fluids. This activity includes standing in the direct care field during the procedure in progress.

Failure of staff to wear appropriate PPE when participating in activities that has potential of contamination of bodily fluids places staff at risk for injury and infection.

5) During observations and tour of the Neonatal Intensive Care Unit (NICU) on the afternoon of 8/18/15 with the NICU Manager and Staff #D., staff #D was observed entering adjoined "pods" of patient #6 and patient #7 without performing hand hygiene. Both patients were admitted within minutes of each other with labored breathing. The respiratory therapist was present to apply respiratory equipment to each patient. The patients were both newborns who had not been bathed at the time of admission. The respiratory therapist was observed placing a nasal cannula on patient #6 and taping it in place without donning gloves.

6) Staff #G in the NICU was then observed exiting the patients pod without performing hand hygiene and then returned to the bedside of patient #7. Staff #G was then again observed placing respiratory equipment in the nostrils of patient #7 without donning gloves.

The observations of no hand hygiene and the staff member not donning gloves prior to touching the both patients were confirmed at the time of finding with staff #4.

Failure of all staff to perform hand hygiene and to don gloves prior to patient care places the patient and staff at risk for infection.