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.
|BAYSTATE MEDICAL CENTER||759 CHESTNUT STREET SPRINGFIELD, MA 01199||Sept. 19, 2017|
|VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES||Tag No: A0749|
|Based on observations, records reviewed and interview the Hospital failed to consistently follow infection control standards for cleaning of equipment, hand hygiene and donning of Personal Protective Equipment.
1.) The Surveyor observed Operating Room #10 at 9:10 A.M. on 9/19/17. The anesthesia chair was positioned near the head of the Operating Room table. The anesthesia chair had wide upholstered arm rests that had several visible worn areas where the material had split and revealed the padding. Because these chairs no longer had intact and cleanable arm surfaces, they could not be adequately cleaned between surgical cases.
The Surveyor interviewed the Nurse Manager for Anesthesia Services at 9:40 A.M. on 9/7/17. The Nurse Manager for Anesthesia Services said she had identified the need for new chairs, however, the chair continued to be used.
2.) The Surveyor observed the pre-surgical set up of Operating Room #10 at 9:15 A.M. on 9/19/17. Operating Room Nurse #1 was assisting the Surgical Technician in opening the sterile packs for the procedure. Operating Room Nurse #1 opened one of the surgical instrument trays and per policy examined the internal filter. After she examined the filter she went to throw it into the trash and the filter landed on the floor. Operating Room Nurse #1 retrieved it from the floor, threw it in the trash and continued to assist the Surgical Technician. Operating Room Nurse #1 failed to perform hand hygiene after retrieving the filter from the floor and before handling the clean items.
3.) The Surveyor observed Operating Room #10 at 9:20 A.M. on 9/19/17. Operating Room #10 was entered by Anesthesiologist #1 who conferred with the Certified Registered Nurse Anesthetist in the room. Anesthesiologist #1 was dressed in his Operating Room attire except he had failed to secure his mask appropriately.