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 observations, records reviewed and interview the Hospital failed to consistently meet infection control standards in high level disinfection, use of multidose vials, transport of biohazard material, complying with standards of practice for N95 use and cleaning of equipment according to the manufacture's directions for use.

1.) The Surveyor toured the Ultrasound area and interviewed Ultrasound Technologist #1 at 9:30 A.M. on 3/21/18. Ultrasound Technologist #1 said she frequently performed high-level disinfection (the process of complete elimination of all microorganisms in or on a medical device between uses) on the probes used in the department. Ultrasound Technologist #1 demonstrated the numerous steps she would take to ensure that she complied with the manufacturer's directions for use. Ultrasound Technologist #1 demonstrated how she would wash the probe in the sink provided in the decontamination room in the Ultrasound department. Ultrasound Technologist #1 said after performing the high level disinfection she would soak the probe to remove the disinfectant as directed by the manufacturer; however, Ultrasound Technologist #1 was using the same sink used to wash the soiled probe as to soak the newly disinfected probe thus increasing the risk of recontamination of the probe.

2.) According to the Center for Disease Control (CDC) standards for Safe Practices for Medical Injections "Multi-dose vials should be dedicated to a single patient whenever possible. If multi-dose vials must be used for more than one patient, they should only be kept and accessed in a dedicated medication preparation area (e.g., nurses station), away from immediate patient treatment areas. This is to prevent inadvertent contamination of the vial through direct or indirect contact with potentially contaminated surfaces or equipment that could then lead to infections in subsequent patients. If a multi-dose vial enters an immediate patient treatment area, it should be dedicated for single-patient use only."

The Surveyor toured the Intensive Care Unit and interviewed the Nurse Manager at 9:00 A.M. on 3/20/18. The Nurse Manager said that the Unit rarely used multidose vials except for some insulin preparations. The Nurse Manager said when the nurse needed to use a multidose vial it was obtained from the medication room and brought to the patient's area where both the multidose medication vial and the patient were scanned to ensure the correct medication was used. The Nurse Manager said the multidose vial was then returned to the medication room for future use.

3.) The Nurse Surveyor toured the Operating Room and interviewed the Charge Nurse at 11:00 A.M. on 3/20/18. The Surveyor asked about a large cooler that was at the Operating Room front desk. The Charge Nurse said the cooler was used to hold specimens from the Operating Room until the pathology laboratory sent someone to pick up the specimens. The cooler had no biohazard sign, as required, to signify that the contents of the cooler were biohazardous.

The Surveyor later observed the transporter retrieve the contents of the cooler and re-pack them into her cooler. The transporter said she was taking the specimens to pathology and her transport cooler also lacked a biohazard label.

4.) The Surveyor toured the Intensive Care Unit and interviewed the Nurse Manager at 9:00 A.M. on 3/20/18. The Nurse Manager said that she and all of her staff were "fit tested " (fit testing is a pass/fail test method that uses your sense of taste or smell, or your reaction to an irritant in order to detect leakage into the respirator facepiece) to the N95 (an N95 respirator is a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) mask upon hire and then every year.

The Surveyor interviewed the Respiratory Therapist at 9:00 A.M. on 3/20/18. The Respiratory Therapist said she would be able to care for a patient that required her to wear an N95 respirator.

The Surveyor reviewed the personnel records of the ICU Nurse Manager, the Respiratory Therapist and two other staff who might be called upon to don an N95. The Personnel records indicated that three of the four sampled had not been fit tested according to the Hospital policy and the OSHA requirements. The ICU Nurse Manager had not been fit tested since 11/1/16, the Respiratory Therapist had not been fit tested since 1/22/16 and the Manager of the Sterile Central Service had not been fit tested since 2/10/16 and had not complied with the requirement for annual fit testing.

5.) The Surveyor reviewed the emergency equipment in the Intensive Care Unit at 9:15 A.M. on 3/20/18 and interviewed the Nurse Manager. The Surveyor observed a container that held the laryngoscope handle, blades and endotracheal tubes used to place an airway into a patient in distress. The Surveyor observed the blades and the endotracheal tubes were stored in plastic peel packs to ensure sterility, however, handles had no designation of being clean.

The Surveyor reviewed the manufacturer's directions for cleaning, disinfecting and storing of the handles. According to the manufacturer (Rusch) both the blades and the handles require high level disinfection or sterilization for reprocessing of these devices.