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Based on observations, staff interviews and record review, the Hospital failed to consistently meet Infection Control standards because 1.) the respiratory protection program (fit testing) did not adhere to Occupational Safety and Health Administration (OSHA) requirements, 2.) expired kits and indicators were observed, and 3.) challenge packs (biological indicator) were observed stored under the sink.

Findings include:

1.) The hospital failed to adhere to the hospital policy and industry standards for a respiratory protection program to comply with the (OSHA) general industry standards in six of seven staff records.

According to OSHA requirements, employees are required to be fit tested (a procedure to ensure correct fit of an employee's respirator/mask) annually. A respirator/mask is used to protect the healthcare worker against diseases spread through the air, e.g., tuberculosis.

Surveyor #1 and #2 interviewed the Employee Health Nurse Practitioner at 1:15 P.M. on 6/26/2013. The Employee Health Nurse Practitioner said fit testing was performed annually. The Review of personnel files indicated fit testing had not been completed annually for six of seven Operating Room personnel.


2.) Surveyor #1 and #2 observed at 8:20 A.M. on 6/25/2013, three expired sterile kits (expired 8-2010, 1-2011, 9-2012) and one box of sterilization indicators (expired 7-2012).


3.) Surveyor #1 and #2 observed at 9 A.M. on 6/25/2013 approximately a dozen Challenge Packs (used to monitor steam sterilization loads and documents successful sterilization cycles) stored under the sink in the sub-sterile room. Challenge Packs must be stored to protect the product from moisture and excess humidity.

Based on record review, the Hospital failed to follow its policy on completing the Informed Consent for Invasive and Surgical Procedures.

Findings include:

According to the Policy, Informed Consent for Surgical and Invasive Procedures, all blank spaces on the consent form must be completed. Review of the ten surgical consent forms indicated 8 of the 10 consent forms did not contain the time of the signatures as the form required.

Based on record review, the Hospital failed to maintain a complete Operating Room (OR) Register.

Findings include:

Surveyor #1 reviewed the OR register on 6/26/2013. The Register lacked documentation of the name of nursing personnel (scrub and circulating), type of anesthesia used and name of person administering the anesthesia, pre and post-op diagnosis, and the age of patient as required.