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, staff interview and record review the facility failed to assure that infection control measures were implemented in an ongoing and consistent manner to assure appropriate storage of patient care equipment and appropriate use of PPE (Personal Protective Equipment) by all staff. Findings include:

1) Per observation, at 3:40 PM on 7/30/12, several endoscopes were stored in a hanging position, in an open cabinet, located in the endoscope reprocessing area. During interview, at the time of observation, Nurse #1 stated that the endoscopes had been reprocessed (the process of high level disinfection) and were stored in the cabinet awaiting reuse for other patients. S/he agreed that scopes should be stored in a closed cabinet, to reduce the risk of contamination or damage while awaiting reuse, and stated that the door to the storage cabinet had been broken for an extended period of time and, because it currently would not close, the scopes were stored uncovered. Per interview, at 8:15 AM on 7/31/12, the Infection Control Nurse agreed that the endoscopes should be covered during storage, in accordance with the facility policy.

2. Per observation, at 2:14 PM on 7/31/12, Physician #1 entered the OR (operating room) in which a surgical procedure was in process, to speak with the anesthesiologist involved in the active surgical case. Physician #1's head cover did not cover all hair and, in addition, the mask s/he was wearing was tied under the nose, exposing the entire nose. Physician #1, at one point, stood at the head of the OR table looking up and over the sterile drape placed near the patient's head, to view the surgical area. During interview, at 4:00 PM that afternoon, the Infection Control Nurse stated that per hospital policy and standard of care, PPE (Personal Protective Equipment), including head covers that completely cover all hair, and facial masks, completely covering nose and mouth, should be worn by anyone entering an OR in which an active case is in progress.