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.

LEGACY MOUNT HOOD MEDICAL CENTER 24800 SE STARK STREET GRESHAM, OR 97030 Sept. 27, 2012
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
A. Based on policy review and review of documentation, it was determined the hospital failed to ensure a system was developed for preventing and controlling infections, including the monitoring of equipment used for sterilizing surgical instruments, in accordance with hospital policy.

Findings included:

1. Review of the policy titled, "Sterilizer Monitoring In Central Sterile-Bowie Dick Test, Internal And External Chemical Indicators, And Biological Testing," revised 08/2012, identified the following internal requirements: "...STERRAD sterilizers will use a biological test daily...results will be recorded."

2. A tour of the Central Processing Area was conducted with I6, the Director of Surgical Services, and I8, a surgery department technician, on 09/25/2012 at 1100. During the tour, a Sterad 100S sterilizer (#45) and a Sterad NX sterilizer (#46) were observed.

3. BI log records titled, "24 Hour Vacuum Sterrad (Rapid Readout) Attest Monitor Log," for sterilizer #s 45 and 46, dated 05/29/2012 through 09/12/2012, were reviewed. The records reflected biological test and control results were not recorded for sterilizer #45 on 08/22/2012 and 09/11/2012; and sterilizer #46 on 07/26/2012 and 09/11/2012.

4. An interview was conducted with I8 on 09/25/2012 at 1100. I8 reviewed the BI records, and acknowledged that the biological test and control results were not recorded daily in accordance with hospital policy.


B. Based on observation, interview, and policy review, it was determined the hospital failed to develop a system for preventing and controlling infections, including development of a policy to ensure that anesthesia equipment in the OR was disinfected between surgical patients. The hospital also failed to ensure environmental surfaces in the OR were disinfected between surgical patients, in accordance with hospital policy.

Findings included:

1. Review of the policy titled, "Operating Room and Cath Lab Housekeeping Procedure," effective 07/2001, identified the following internal requirements: "...Post-Procedure...All flat surfaces are cleaned with a disinfectant...Computer keyboards/keyboard covers should be damp wiped down..." Review of the policy identified it was not fully developed to ensure anesthesia equipment in the OR was disinfected between surgical patients.

2. A surgical procedure for Patient #2 was observed on 09/25/2012 at 1030. The anesthesia cart and equipment were positioned near the patient's head. Items on the top of the anesthesia cart included a towel, a computer keyboard, a computer mouse pad, and a computer mouse. A computer touch screen was attached to the cart. During the procedure, I5, an anesthesiologist, touched the patient's mouth and nose area, then touched the anesthesia cart, including a gas flow control knob, and the computer screen. An interview was conducted with I5 on 09/25/2012 at 1035, during the procedure. He/she stated that "techs" disinfected the anesthesia equipment between cases. After the surgical procedure was completed, the patient was removed from the room, and the room cleaning procedure was observed. The items on the anesthesia cart, including the gas flow control knob, were not cleaned or disinfected. Additionally, the computer keyboard and computer touch screen, were not wiped down or disinfected, in accordance with hospital policy. These observations were conducted with I28, an ACC, present.

These findings were reviewed with I6 on 09/26/2012 at 1050.


C. Based on interview, policy review, and review of documentation, it was determined the hospital failed to develop a system for controlling infections, including development of a policy to ensure that the ORs were terminally cleaned after the last procedure of the day, when the procedure was not conducted during the regular work week, as required.

Findings included:

1. Review of the policy titled, "Operating Room and Cath Lab Housekeeping Procedure," effective 07/2001, included the following internal requirements: "...Terminal cleaning and disinfection of operating and invasive procedure rooms should be done when the scheduled procedures are done for the day and each 24-hour period during the regular work week..."

2. Review of the policy titled, "O.R. Block Scheduling-Mount Hood Medical Center," reviewed by the hospital 09/27/2012, reflected, "...Elective Cases: Patients who are safe to schedule past 24 hours following determined need for surgery...Urgent Cases: Patients needing surgical intervention within 24 hours...Emergency (life-threatening) Cases: Patients needing surgical intervention as soon as possible."

3. A list of weekend surgical procedures, titled, "Operating Room Add-On Cases," for 07/14/2012 through 09/23/2012, was reviewed. Review of the list reflected that 38 weekend procedures (20 on Saturdays and 18 on Sundays) were conducted during that timeframe.

4. An interview was conducted with I6 on 09/25/2012 at 1015. He/she stated ORs were terminally cleaned daily during the regular surgery work week, which was Monday through Friday. He/she stated ORs were not terminally cleaned on weekends. A second interview was conducted with I6 on 09/26/2012 at 0900. He/she reviewed the list of weekend surgical procedures. He/she stated he/she didn't think any of the procedures on the list of weekend surgeries were emergency procedures. He/she stated they were "emergent," but not emergency procedures. However, he/she further stated they were not scheduled procedures either, and therefore the ORs were not terminally cleaned after the last procedure of the day was performed. Review of the policies above, identified they were not fully developed to clearly define which surgical procedures were "scheduled," and to ensure that the ORs were terminally cleaned on weekends, after the last procedure of the day.


D. Based on observation and policy review, it was determined the hospital failed to develop a system for preventing and controlling infections, including the development of a policy to ensure that all surfaces in the OR were cleanable surfaces, as required.

Findings included:

1. A tour of the surgical services department was conducted with I6 and I28 on 09/25/2012 at 1050. OR #s 2 and 3 were observed during the tour. OR #2 had chipped paint on the inside walls to the right and left of the OR entrance door, and around the inside areas of the door frame. The wall mounted X-ray bank had an uneven, adhesive-like residue around the framework. OR #3 had chipped paint on the inside wall to the right of the OR entrance, and around the inside areas of the door frame. These observations were conducted with with I6 and I28 present. During the observations, I6 acknowledged that the ORs had areas of peeling paint.

2. A policy titled, "Operating Room and Cath Lab Housekeeping Procedure," effective 07/2001, was reviewed. The policy was not fully developed to ensure that all surfaces in the OR were cleanable.


E. Based on staff interview, it was determined the hospital failed to develop a system for preventing and controlling infections, including the development and implementation of a policy and procedure for cleaning equipment used for respiratory treatments, as required.

Findings included:

1. An interview was conducted with I20, a respiratory therapist. He/she stated that the hospital used disposable medication nebulizer equipment. I20 stated the equipment was changed if the patient remained at the hospital for more than a few days, and was sent home with patients when they were discharged . However, he/she stated the equipment was not routinely cleaned after each use.

2. An interview was conducted with I12, an ACC on 09/26/2012 at 1640. He/she stated the hospital did not have a current policy for routinely cleaning medication nebulizer equipment.


F. Based on observation, interview, and policy review, it was determined the hospital failed to develop a system for preventing and controlling infections, including full development and implementation of a policy for patients on contact isolation precautions, as required.

Findings included:

1. Review of the policy titled, "Isolation Precautions," reviewed 09/2011, identified the following internal requirements: "...use Contact Precautions for patients known or suspected with microorganisms that can be transmitted by direct contact with the patient or by contact with items in the patient's environment...Gloves and Handwashing: Wear gloves when entering the room...Gown: Wear a gown that is impermeable to fluids if you anticipate that you or your clothing will have contact with the patient, environmental surfaces or items in the patient's room..." The policy did not identify how staff would anticipate circumstances where contact would occur. Therefore, the policy was not fully developed to ensure that staff donned a gown prior to contact with the patient, environmental surfaces, or items in the patient's room.

2. A tour of the medical unit was conducted with the I2, the Manager of Medical Specialties, on 09/26/2012 at 1300. During the tour, I2 stated that Patient #5 was on contact isolation precautions.

3. On 09/26/2012 at 1300, I22, a wound ostomy nurse, entered Patient #5's room. The patient was in the bed. The foot of the bed was in close proximity to the doorway entrance. The patient stated he/she had a MRSA infection to his/her right foot wound. I22 stated the patient had Clostridium difficile and was on contact isolation precautions. I22 removed an outer dressing from the patient's right foot. The remaining dressings and the patient's exposed toes were visibly discolored with a brown substance. I21, a physician, entered the room, walked past the patient's foot/exposed toes, and across the room to the sink area. He/she gloved, picked up a urine sample, and then exited the room. His/her coat made contact with the foot of the bed as he/she exited the room. He/she did not don (put on) gloves or a gown when entering the room. These observations were conducted with I22 present; and reviewed with I2 and I28, on 09/26/2012 at 1350.

4. On 09/26/2012 at 1320, I23, a nurse, entered Patient #5's room. I23 walked across the room, and touched the patient's IV pump. He/she did not don gloves prior to touching the pump, or as he/she entered the room, in accordance with hospital policy. These observations were conducted with I22 present.

5. An interview was conducted with I22 on 09/26/2012 at 1400. He/she was asked what the hospital's policy was for glove and gown use when entering the room of a patient on contact isolation precautions. He/she stated that staff were not required to wear gloves or a gown if they were not going to touch anything in the room. I2 and I28 were present during the interview.