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, interview and record review, the facility failed to clean non-critical items between patients, obtain biological indicators for the sterilizer in the GI Lab, properly sterilize hinged instruments, maintain a humidity and temperature log in the Operating Room Suite and assure respiratory procedures are performed in a manner consistent with hospital infection control policies and procedures.

Findings include:

Cleaning of non-critical items

At 8:50 AM, Patient #1 was admitted for an EGD and colonoscopy. RN, Employee #7 was observed during the admission physical assessment. The RN did not clean the stethoscope, temperature probe or oxygen saturation device after use on the patient.

At 9:25 AM, the Director of Surgery acknowledged all instruments were to be cleaned using an anesthetic wipe. The facility used Super Sani wipes.

On 10/26/11 at 9:40 AM, the Infection Control Nurse acknowledged all equipment used on patients required to be cleaned with Super Sani Wipes between patients.

The Definition: Care of Contaminated Articles and Equipment policy IC:04:03 renewed 09/11 was reviewed. Non critical "1. Follow a protocol for cleaning or, if necessary a low-level disinfection process."

Biological indicators

At 10:25 AM, the GI Laboratory Technician, Employee #9, was observed cleaning the scopes after the procedure. The employee was unable to produce a biological indicator log. At 1:30 PM, the employee acknowledged biological indicators were not performed on the sterilizer and he had never been taught to perform a biological indicator. The employee explained the chemical indicators were thrown away after sterilization. The employee stated he had been trained by his predecessor.

Review of the Steris manual revealed biological indicators were to be performed. The manual discussed use of Chemical Monitoring strips.

The Definition: Care of Contaminated Articles and Equipment policy IC:04:03 renewed 09/11 was reviewed. 4. Biological Monitoring of Sterilizers: "a. All sterilizers should be monitored at least once a week with commercial preparations of spores intended specifically for that type of sterilizer (i.e. Bacillus stearothermophilus for steam sterilizers and Bacillus subtilis for ethylene oxide and dry heat sterilizers)."

On 10/26/11, at 12:50 PM, the Biomedical Director explained the Biomed department checks all sterilizers every six months. The employee explained the hospital was responsible to obtain biological testing on a weekly basis.

On 10/25/11, the Director of Surgery explained the employees receive annual competency testing. There was no documented evidence of the employees responsible for scope cleaning received an in-service from the sterilizer manufacturer.

Review of the Competency, Orientation, Education & Training Guidelines policy ADM:03:01 revised 11/10 was reviewed. Definitions: Annual and ongoing competency assessment: "Unit- Specific - Each department will identify competencies for which annual and ongoing validation will be required and establish a process for validation and documentation. Selection of skills for competency validation will be based on those, which are high risk, problem prone, low volume, regulatory required, new or essential."

On 10/25/11, review of five Surgical Technician employee files was conducted.

Employee #9 was hired on 10/23/95. There was no documented evidence the employee provided demonstration use of the sterilizer and Steris after 2006.

Employee #12 was hired on 3/2/98. There was no documented evidence the employee provided demonstration use of the sterilizer and Steris after 2008.

Employee #13 was hired on 2/18/08. There was no documented evidence the employee provided demonstration use of the sterilizer and Steris after 2008.

Employee #14 was hired on 10/19/04. There was no documented evidence the employee provided demonstration use of the sterilizer and Steris after 2008.

Employee #15 was hired on 6/14/93. There was no documented evidence the employee provided demonstration use of the sterilizer and Steris.

Sterilization of hinged instruments in the Operating Room Suite

On 10/26/11, at 8:10 AM, a tour of the surgery suite was conducted. An interview was conducted with the Sterile Processing Technician, Employee #17.

Four of four clamps sterilized were observed to have been sterilized with the clamps closed. Observation of the cupboard of sterilized Metz, curved mayo, jergenson, babcock, allis, sponge sticks, right angle, peons, Kelly, scissors and needle holders were noted to have been sterilized clamped. The Sterile Processing Technician was not sure why the clamps were sterilized closed. The employee acknowledged the clamps and scissors in the cupboard had been sterilized closed and should have been open during sterilization. There was no identified policy or procedure for wrapping instruments for sterilization.

Employee #17 was hired on 3/3/03. There was no documented evidence the employee provided demonstration use of sterile processing after 2008.

Employee #22, the housekeeper was interviewed on 10/26/11 at 8:50 AM. The employee explained she would check the temperature and humidity of the operating rooms daily and enter the results into the log. The employee explained the log had been missing for quite awhile.

The temperature in OR #5 registered at 64 degrees with humidity at 26%. The Director of Surgery was unable to produce the temperature and humidity log for October. The last entry into the log was in June 2011.

Surgical Suite Temperature and Humidity policy STER:01:17 formulated 04/08 was reviewed. "A designated person shall read the temperature and humidity gauges in the surgical suite daily and the results will be recorded on the log." Ventilation and Humidity: "3. Maintain temperature at 65-75F"

On 10/26/11 at 11 AM, Employee #20 was observed changing the ventilator tubing (Ballard) on Patient #4. The employee stated Ballards were changed daily. Upon review of the medical record, there was no documentation of a Ballard change, or ventilator circuit change for 2 weeks. Patient #5 medical record was reviewed. There was no documented evidence of ventilator circuit change was noted in the record for 3 weeks.
The facility policy named RT:0247 documented "change ventilator circuit every seven days or more often and documentation of the circuit change will be on the medical record".
Based on observation, interview and document review, the facility failed to follow aseptic technique for the intramuscular injection of Patient #2.

On 10/25/11 at 8:35 AM, a tour of the pre-operative area was completed. RN, Employee #6 was observed administering and injection of Heparin to Patient #2. The RN did not wipe off the top of the vial of Heparin and administered the injection without wearing gloves. The RN acknowledged she did not wipe off the heparin or wear gloves for the injection.

Medication Administration policy RXMM 5.10.01 renewed 10/06 was reviewed. Procedure: 1. "Observe Aseptic technique."

Intramuscular injection procedure revised 7/9/11 was reviewed. Preparation of Equipment: "For single-dose or multidose vials: Wipe the stopper of the medication vial with an alcohol pad, and then draw up the prescribed amount of medication." "Put on gloves" "Remove and discard your gloves and perform hand hygiene."

Based on observations, interviews, and documentation review, the facility failed to ensure the staff members following policies and procedures regarding hand hygiene, isolation precautions, cleaning and disinfecting non critical medical equipment.
Findings include:
On 10/25/2011 at 10:13 AM, during the tour of the facility, employee #28 was observed performing blood glucose finger stick test to a patient in room #2028 in the towel 2. After the procedure, employee #28 did not clean the glucometer. She removed her glove and did not perform hand hygiene.

At 10:20 AM, employee # 28 gave the glucometer device to employee # 29. Employee #29 went to room # 2031 to perform blood glucose test to a patient. She did not clean the glucometer and she did not perform hand hygiene. The procedure was stopped and employee # 29 was requested to clean the glucometer before perform the next blood glucose test.

At 10: 30 AM, employee # 28 was interviewed about cleaning and disinfection of the glucometer. She stated glucometers are disinfected at least once daily by night shift.

At 10:50 AM, employee # 3 was asked about cleaning and disinfection of the glucometers. She affirmed glucometers are cleaned after each use with Sani-Cloth ?. She also stated employees get annual training on the use of glucometer that include cleaning and disinfection procedures.

Facility policy titled "Blood glucose monitoring " revised April 02, 2011 read: "... Clean and disinfect the blood glucose monitor between each patient contact ..."

On 10/25/2011 at 1:18 PM, a thoracentesis procedure was observed in isolation room #2029. During the procedure, employee #30 was used her personal cell phone three times and putting it back in her packet. Employee #30 was asked about the use of the personal phones in the isolation room. She stated she should not have used her cell phone during the procedure.
At 1:41 PM, , employee #30 put a bottle with body fluids from the thoracentesis, over the bed of the patient, them inside the transparent zipped plastic back and not into a biohazard bag, and posteriorly into the ultrasound machine cart. Employee #30 was interviewed about the bottle with thoracentesis specimen. She affirmed the bottle was placed into zipped bag to avoid liquid spill.