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Based on records review, tour and interviews, it was determined that the facility failed to appropriately monitor the autoclave room and sterilization process for Mesa Hills Wound Care and Hyperbaric Medicine Center.

Findings were:

? A tour of the facility on 9/11/12 revealed that the autoclave room had two blank logs, one entitled "Mesa Hills/Wound Care Daily Autoclave Log", and the other was entitled "Biological Indicator Test Results".

In an interview with the Wound Care Project Director during the tour, she stated that the logs were new and created after 9/6/12. She also stated that prior to 9/6/12 no logs were kept for either biological indicator results or daily autoclave activity. Documentation related to daily autoclave use and biological indicators is necessary for monitoring the effectiveness of the autoclave and ensuring that instruments are appropriately processed in the autoclave; without documentation it cannot be ensured that instruments were adequately sterilized.

? In an interview with the Wound Care Project Director, on the morning of 9/11/12, she stated the following: On 9/6/12 it was discovered that enzymatic cleaner was not used on instruments (used for debridement of wounds) prior to placement in the facility's autoclave for approximately the past 3 to 4 months. She stated that when the enzymatic cleaner ran out 3 to 4 months ago the Wound Care Technician who sterilized instruments (personnel #1) did not re-order any and continued to work without it. During the interview she confirmed that instruments should be cleaned with an enzymatic cleaner prior processing them in the autoclave.

? Review of personnel #1's employment record on 9/11/12 revealed that he had no evidence that indicated that he was oriented or trained in the sterilization of instruments. His file indicated that he began employment as a Wound Care Technician at the facility in July of 2007. The Wound Care Project Director confirmed these findings on the morning of 9/11/12.

? The facility failed to have an infection control officer responsible for the off-site location in which the above findings were made:

Cross reference tag A0748 Infection Control Officer(s)

Based on review of documents and interview, it was determined that the facility failed to develop a policy and procedure or competency requirements related to sterilization.

Findings were:

Review of the facility's policies and procedures, on 9/11/12, revealed that the facility's off-site location, Mesa Hills Wound Care and Hyperbaric Medicine Center, did not have a policy and procedure or competency requirements for sterilization of instruments.

The above findings were confirmed in an interview with the Wound Care Project Director on the morning of 9/11/12.

Based on record review and interview, it was determined that the facility failed to have an infection control officer responsible for an off-site location, Mesa Hills Wound Care and Hyperbaric Medicine Center.

Findings were:

In an interview with the facility's Quality and Infection Control Manager on the morning of 9/11/12, she stated that the Mesa Hills Wound Care and Hyperbaric Medicine Center did not have an infection control officer for 7 months prior to 7/31/12.

The facility's Infection Control Meeting Minutes, reviewed on 9/11/12, from December 2011 to May 2012 provided no evidence to indicate that Mesa Hills Wound Care and Hyperbaric Medicine Center had an infection control officer.

The above findings were confirmed in an interview with the Chief Nursing Officer on the morning of 9/11/12.