HospitalInspections.org

Based on record review and interviews with hospital staff, the governing body does not ensure that all services performed under contract are provided in a safe and effective manner. Services provided to the hospital by contract are not monitored and evaluated by the hospital's quality assessment and performance improvement (QAPI) program to ensure that they are provided in a safe and effective manner.

Findings:

1. Review of the hospital's QAPI , Medical Staff and Governing Board committee minutes for the previous twelve months did not have evidence that services provided by a contracted provider were evaluated and reviewed.

2. Review of the hospital's current QAPI plan did not include the evaluation of contracted services in the plan.

3. According to hospital staff ( B, C & G ) on 04/19/10 in the afternoon, the hospital does not have a mechanism to evaluate the quality of each contracted service through the hospital's QAPI program.

Based on staff interviews and policies and procedures, the hospital failed to ensure the infection control officer maintained a comprehensive system for controlling infections and communicable diseases. The infection control officer did not monitor the surgery department to ensure appropriate measures were taken regarding the sterilization of surgical instruments to avoid potential sources and transmission of infections. The hospital utilizes "flash" method of sterilization.


Findings:

1. During an interview with the surgery department charge nurse in afternoon of 04/19/10, the surveyor asked if and when flash sterilization was utilized. The charge nurse replied " every time for a (physician identifier) case." When the surveyor asked why, the charge nurse replied he has certain instruments he likes to use and there are not enough of them."

2. The policy and procedure for flash sterilization could not be produced at the time of the survey.

The Centers for Disease Control and Prevention (CDC -- from Infection Control and Hospital Epidemiology, "Guideline for Prevention of Surgical Site Infection", April 1999, page 261; and from Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, page 61) and the Association of Operating Room Nurses (AORN -- Perioperative Standards and Recommended Practices, pages 578 through 581, 2008 edition) do not recommend the use of "flash" sterilization for the routine sterilization of instruments, reasons of convenience or as an alternative to purchasing additional instrument sets or to save time. "Flash" sterilization, according to current CDC guidelines, should be limited to the purpose of sterilizing a surgical instrument in an emergency, such as when a needed instrument has been dropped or otherwise became contaminated.