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Based on observation, interview, and record review, the hospital failed to implement infection control practices when:

1. Sterilized surgical instrument trays contained reddish/brown stains.

2. The Central Service department was not maintained in a sanitary condition; there was severe damage to the floor and walls; baseboards were missing potentially allowing vermin to enter the department; supplies were not stored in a manner to prevent contamination; and cardboard was stored in multiple locations in the department.

This had the potential to result in hospital acquired infections requiring continuing treatments.

Findings:

1. During an observation and interview with the Charge Nurse Surgery (CN) and Surgical Technician (ST), on 2/19/19, at 1:10 PM, in the surgery sterile instrument storage room, the ST opened two sterilized surgical instrument trays. The trays contained multiple types of clamps, scissors, and retractors (instrument that holds tissue). There were approximately 14 round spots of reddish/brown/rust colored stains, under the tips/handles of the instruments where they made contact with a white paper tray liner (PTL-paper that helps absorb moisture). The CN and ST verified the stains on the PTL in both instrument trays and stated they did not know the cause of the stains. The CN stated the discoloration was first noticed in the trays in December (2018).

During an observation and interview with the Director of Infection Prevention (DIP), Infection Prevention Coordinator (IPC), the CN, and the CRCST (Certified Registered Central Service Technician) on 2/20/19, at 9:40 AM, in the surgery sterile instrument storage room, two sterilized surgical instrument trays were opened by the CRCST. Both instrument trays had evidence inside of reddish/brown/stains on the white PTL. The discoloration was observed under multiple instrument handles and in multiple locations between the instruments. The DIP, the ICP, the CN, and the CRCST verified the discoloration/staining on the PTL. The DIP stated the discoloration/staining was first noted three months ago. The CN and CRCST verified the discoloration/staining and stated it was first seen in December (2018) or January (2019).

2. During an observation and interview with the Materials Manager (MM), on 2/19/19, at 2:05 PM, in Central Supply (CS-department that stores and distributes supplies to departments in the hospital), the cement floor had damaged areas including large, long, uneven cracks and missing pieces of cement throughout the department. The walls had multiple areas of damage, including missing pieces of plaster throughout the department. The CS department was 3,259.4 square feet in size. The cracks began at the entrance doors and continued throughout the entire floor space of the CS to the exit doors. Many of the cracks were up to one inch wide and contained light brown, dark brown and black debris. There were two holes in the floor next to a supply cart with sterile supplies on the shelves. Each of the holes was approximately one inch wide by one inch deep. The holes were filled with dirt and debris. There were large areas of stains on the floor and under the supply carts. Baseboard trim was missing from most of the length of one wall. Pieces of wood from the baseboard trim, rubber from the wheels of the supply carts and packages of patient supplies were on the floor under the carts. Along one wall there were storage racks with stacks of supplies, separated by dividers. Attached to the wall was a double wall trim, approximately one inch in width, that was embedded with electrical outlets. Most of the supplies were in contact with the trim that was covered with a thick layer of brown dirt and debris. The MM verified the wall trim was covered with dirt and debris and the supplies were in contact with the dirt and debris on the trim. Two carts with multiple shelves, contained sterile (free from bacteria) and unsterile supplies. The carts contained approximately 70 packages of sterile drapes (disposable material to cover a patient during a surgical procedure). The sterile drapes were not contained in a bin or bag to prevent them from sliding on to the floor. Three carts were observed without solid bottom shelves. The MM verified the shelves had no solid bottoms and the sterile supplies were not stored to prevent them from sliding off of the shelf and on to the floor. Twelve packages of sterile tubing had the expiration dates circled in black felt tip pen on the surface of the packaging. The MM verified the expiration dates were circled with a black felt tip pen and the packages were no longer sterile. Multiple carts had cardboard boxes containing various supplies stored on each shelf, and on tops of the carts. Some cardboard boxes were opened with sterile supplies remained inside. The MM verified there were multiple carts used for storage of cardboard boxes in the CS department.

During an observation and interview with the Chief Executive Officer (CEO), Chief Operating Officer, DIP, IPC, and the MM, on 2/20/19, at 9 AM, in the CS department, the CEO verified the above findings and stated the department needed to be cleaned and repaired

The Association of periOpeartive Registered Nurses Guidelines for Perioperative Practice 2019 Edition, indicated Recommendation III "III.a.1. Carts should have solid bottom shelves . . . Solid bottom shelves protect the packages on the cart from contaminants on the floor." Recommendation IV indicated "Limiting exposure to moisture, dust, direct sunlight, handling . . . decreases the potential for contamination and degradation of sterilized items. Factors that contribute to contamination include handling, air movement, humidity, temperature, location of storage, dust, presence of vermin." Recommendation IV.c indicated "Supplies and equipment should be removed from external shipping containers and open-edged corrugated boxes before transfer to the . . . storage area. External shipping containers and open-edged cardboard boxes may collect dust, debris, and insects during shipment and may carry contaminants."

The hospital's Infection Prevention and Control Plan, dated 2019, indicated "Surveillance will be a blend of on going physical presence in all areas of the facility . . . Direct observation, in the Infection Prevention & Control rounds. . . The Infection Prevention and Control Program is designed to identify the potential for disease transmission, recommend risk reduction practices by integrating principles of infection prevention and control and patient safety into all direct and indirect standards of practices."