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.
| MILTON S HERSHEY MEDICAL CENTER | 500 UNIVERSITY DRIVE HERSHEY, PA 17033 | July 10, 2012 |
| VIOLATION: INFECTION CONTROL OFFICER(S) | Tag No: A0748 | |
| Based on a review of facility policy, observation, and staff interviews (EMP), it was determined that Milton S. Hershey Medical Center failed to follow their adopted Infection Control policy related hand hygiene. Findings include: 1) A review on July 9, 2012, of facility policy, "Hand Hygiene," revised January 2012, revealed "A.1. Hand Hygiene is required with either waterless sanitizer or soap and water: ... Upon entering or leaving a patient room or patient care area ...". Observation of the 5th floor Nursing Unit on July 9, 2012, at 2:20 PM revealed a nurse came out of a patient room and did not wash his/her hands. Further observation revealed a physician entered a patient room and did not wash his/her hands. An interview conducted on July 9, 2012, with EMP5, who accompanied the tour, confirmed that the staff members should have washed their hands upon entering and exiting the patient rooms. 2) Observation on July 9, 2012, at 12:15 PM of the Interventional Radiology Suite revealed that EMP11 completed the procedure and did not perform hand hygiene after removing their gloves. An interview conducted on July 9, 2012, at 12:40 PM with EMP11 confirmed they did not perform hand hygiene after removing their gloves. |
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| VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES | Tag No: A0749 | |
| Based on a review of facility policy, observation and staff interviews (EMP), it was determined that Milton S. Hershey Medical Center failed to ensure that personnel followed their adopted practices to prevent infections. Findings Include: 1) A review on July 10, 2012, of facility policies failed to reveal a policy for cleaning the respiratory nebulizer (Mask/mouthpiece, cup) after patient use. Observation on July 10, 2012, of Respiratory staff administering a treatment revealed EMP12 administered a respiratory nebulizer treatment to a patient. Upon completion of the treatment, EMP12 failed to rinse the nebulizer with sterile water and allow it to dry. An interview conducted on July 10, 2012, at 2:00 PM, with EMP13 confirmed the facility did not have a policy for rinsing the nebulizer with sterile water and allowing it to dry following treatments. EMP13 confirmed that EMP12 failed to rinse the nebulizer with sterile water and allow it to dry following the treatment. An interview conducted on July 10, 2012, at 1:45 PM, with EMP12 confirmed the respiratory nebulizer was not rinsed with sterile water and allowed to dry following the treatment. 2) A review on July 9, 2012, of facility policy, "Environmental Cleaning in the Surgical Practice Setting" last reviewed March 2012 revealed, "Operating Rooms must be cleaned before and after each surgical procedure and at the end of each day to reduce the amount of dust, organic debris and microbial load in the surgical environment. Operating Rooms and scrub/utility rooms must be terminally cleaned once during each 24-hour period during the regular work week. Both ongoing and terminal cleaning is extremely important because they not only decrease microorganisms and contamination risks but also may contribute to control and prevention of infections in patients. ... ." Observation on July 9, 2012, of Operating Room (OR) 14 revealed that the OR had just been cleaned and the counter and air exchange grills were covered in dust. Observation on July 9, 2012, of OR 5 revealed the air exchange grills were dusty and the inside of a container, that held Vacutainer tubes, contained a large amount of dust. An interview conducted on July 9, 2012, at 10:30 AM with EMP14, confirmed OR 5 and OR 14 air exchange grills were dusty and the inside of the canister of Vacutainer tubes, was very dusty in OR 5. 3) A review on July 9, 2012, of facility policy, 'Environmental Cleaning in the Surgical Practice Setting," last reviewed March 2012 revealed, "... Guidelines for cleaning sub-sterile room and scrub room: ... Damp Wipe the Autoclaves. ... Scrub floors ... ." Observation on July 9, 2012, of the Sterile Processing Room revealed there was a thick layer of dust on the bottom and the top of the autoclaves, and in the air exchange grills over the autoclaves. Further observation revealed the floor where the sterile OR equipment was stored was dirty. An interview conducted on July 9, 2012, at 3:45 PM, with EMP3, confirmed there was a thick layer of dust on the bottom and the top of the autoclaves, and in the air exchange grills over the autoclaves. EMP3 confirmed the floor where the sterile OR equipment was stored was dirty. 4) A review on July 9, 2012, of facility policy, "Surgical Attire," effective April 2012 revealed, "Purpose: To provide guidelines for attire worn within the semi-restricted and restricted areas of the surgical environment. ... Scrubs must be covered when leaving the department. If you go outside with scrub attire it must be covered; Scrub attire must be changed upon return to the department. ... Head and facial hair must be covered, this includes sideburns and necklines. ... All masks must be removed before leaving the department and placed in the appropriate trash receptacle. ... ." Observation on July 9, 2012, revealed there were three males in the Courtyard wearing surgical scrubs that were not covered and surgical masks that were on backwards and tied around their necks. An interview conducted on July 9, 2012, at 11:30 AM with EMP14, revealed the three males in the Courtyard were Surgical Residents who work in the OR's. EMP14 confirmed that the three Residents in the Courtyard with surgical scrubs did not have their scrubs covered and that their surgical masks were on backwards and tied around their necks. EMP14 also stated that masks and scrubs were not changed when the Residents return to the OR's and masks were not changed when OR staff go from one OR to the next. Observation on July 9, 2012, revealed that in OR 14 there were multiple staff with either neckline hair, sideburns and/or beards, that were not covered completely while an operation was in progress. An interview on July 9, 2012, at 11:30 AM, with EMP14 confirmed that in OR 14 there were multiple staff with either hair or beards that were not covered completely while an operation was in progress. 5) A review on July 9, 2012, of facility policies failed to reveal a policy for daily documentation of monitoring of the Airborne Infection Isolation Rooms. Observation of multiple Airborne Infection Isolation Rooms on July 9-10, 2012, revealed the rooms contained a visual indicator and an audio alarm to alert staff when the rooms were not maintaining proper pressure. The facility could not provide documentation that monitoring was done on a daily basis. An interview conducted on July 9, 2012, at 10:00 AM, with EMP2 confirmed that there was no policy or daily documentation of air pressure monitoring for the Airborne Infection Isolation Rooms. 6) A review on July 9, 2012, of facility policies failed to reveal a policy restricting traffic in and out of the OR to essential staff. An interview conducted on July 9, 2012, at 12:30 PM, with EMP14 and EMP15 revealed that for an average cardiac case that lasts for four to five hours, staff enter and leave the OR approximately 15 times during the operation. EMP14 and EMP15 confirmed that some of the staff does not need to enter and leave the OR during an operation. 7) A review on July 9, 2012, of facility policy titled Cleaning Procedure for Occupied Patient Rooms, last revised January 2012, revealed, "... 6. Clean over bed table if it is not in use and window sill. ... ." The policy did not address cleaning of the patient bed rails. Observation on July 9, 2012, at 3:00 PM revealed EMP6 cleaning a patient room. The patient and bed were not in the room at the time of the room cleaning. The bedside table was present and contained a newspaper, dentures, and cell phone. EMP6 stated, "We were taught not to touch patient's personal items." The bedside table was not cleaned by the worker. EMP6 stated that "I don't routinely wipe down the bed rails because the patients are only here 1-2 days." 8) A review on July 10, 2012, of facility policy titled Cleaning of Non-Critical Equipment in Patient Care Areas, last reviewed March 2010, revealed the frequency of cleaning a glucometer was " .. Between patients if taken into a room ... ." Observation of the 4th floor Nursing Unit revealed an employee taking a glucometer from one patient room into a second patient room, without disinfecting the glucometer. The employee was also observed taking a pair of clean gloves and laying them on a sink, disinfecting his hands, and then applying the gloves that were laying on the handwashing sink. An interview conducted on July 10, 2012, at 11:30 AM, with EMP16 confirmed that the employee should have cleaned the glucometer between patient use. 9) A review of facility policy titled Point of Care Testing, #5 glucose: SureStep Flex, last revised November 2011, revealed, "... Store control solution below 30 degrees C. Discard any unused portion 3 months after opening. ... ." Observation of the Neuroscience ICU on July 10, 2012, revealed a control solution bottle that was dated as opened on April 8, 2012, that had not been discarded after three months. A second opened control solution bottle contained an illegible date. An interview conducted on July 10, 2012, at 11:10 AM, with EMP8 confirmed the first control solution had not been discarded after three months. EMP7 confirmed that they could not read the expiration date on the second control solution bottle. 10) Observation on July 10, 2012, at 9:10 AM, of an Airborne Infection Isolation Room revealed a "pink ball" is built into the wall and is sucked into the wall when the door is closed. The room is maintaining proper pressure when the ball is sucked into the wall. The surveyor asked for the door to be closed. The ball maintained it's position and did not "suck into the wall." An interview conducted on July 10, 2012, at 9:10 AM, with EMP9 confirmed the ball was not functioning properly. 11) A review of facility policy titled Droplet Precautions, last reviewed November 2010, revealed, " ... Wear a surgical mask with ties when working within six (6) feet of the patient. ... ." The policy did not address staff removing the mask when exiting the room. Observation of the 6th floor on July 9, 2012, at 2:00 PM, revealed a patient was Contact Isolation. A nurse exited the room and did not remove and dispose of their mask. The nurse pulled the disposable mask off of his/her face and allowed it to hang around his/her neck as the nurse went to the Nursing Station. An interview conducted on July 9, 2012, with EMP10 at 2:00 PM confirmed the staff member did not remove the mask upon exiting the patient room. |
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