| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 01C0001002 | (X3) Date Survey Completed 04/10/2025 |
| Name of Provider or Supplier Mobile-Sc, Ltd | Street Address, City, State 6144 A Airport Boulevard, Mobile, AL | |
| For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency. | ||
| (X4) ID Prefix Tag | Summary Statement of Deficiencies
(Each deficiency should be preceded by full regulatory or LSC identifying information) |
| E0000 | A recertification survey was conducted on 4/8/25 to 4/10/25 and Mobile Surgery Center was found to be in substantial compliance with the Conditions for Coverage for Emergency Preparedness. |
| Q0000 | A recertification survey was conducted on 4/8/25 to 4/10/25 at Mobile Surgery Center, an Ambulatory Surgical Center with five Operating Rooms and three Procedure Rooms. Standard Level deficiencies were cited and will require an acceptable Plan of Correction. |
| Q0181 | ADMINISTRATION OF DRUGS CFR(s): 416.48(a) Drugs must be prepared and administered according to established policies and acceptable standards of practice. This STANDARD is not met as evidenced by: Based on observations, review of facility policy and procedure, and interviews it was determined the facility failed to ensure opened single dose vials were not available for patient use and discarded per facility policy. This deficient practice had the potential to affect all patients served by this facility. Findings include: Facility Policy: Safe Use of Single Dose, Single Use and Multi-dose Vials Policy Number: None Date Revised: 1-2025 Policy: Mobile Surgery Center adheres to the CDC (Center for Disease Control) and USP (United States Pharmacopeia) regulations for safe use of single dose, single use, and multi-dose vials. Procedure: The following apply to the use of single dose...vials of medication. I. Single Use Vials: A single-dose or single-use vial is a vial of liquid medication intended for parenteral administration (injection or infusion) that is meant for use in a patient for a single case/procedure/injection... A. If a single-dose...vial appears to contain multiple doses or contains more medication than is needed for a single patient, that vial will not be used for more than one patient nor stored for future use on the same patient. B. ...the vial must be discarded at the end of the procedure and not stored for future use... An observation of Operating Room (OR) # 3 conducted on 4/8/25 at 1:30 PM revealed an opened single-dose vial of 1 % (percent) Lidocaine Hydrochloride 50 mg (milligram) /5 ml (milliliter) in a locked narcotic box available for patient use. Employee Identifier (EI) # 6, OR Registered Nurse confirmed at the time of the observation the vial was opened and available for patient use and not discarded. |
| Q0242 | INFECTION CONTROL PROGRAM CFR(s): 416.51(b) The ASC must maintain an ongoing program designed to prevent, control, and investigate infections and communicable diseases. In addition, the infection control and prevent program must include documentation that the ASC has considered, selected, and implemented nationally recognized infection control guidelines. This STANDARD is not met as evidenced by: Based on observations, review of facility policy, staff interviews and AORN ( Association of periOperative Registered Nurses) Guideline Essentials: Key Takeaways- Hand Hygiene, it was determined the facility failed to ensure staff performed hand hygiene per facility policy and AORN Guidelines. This deficient practice had the potential to negatively affect all patients served by the facility. Findings Include: Facility Policy: Handwashing Policy Number: None Revise Date: 1/2016 Purpose: Improved adherence to hand hygiene has been shown to terminate outbreaks in health care facilities, to reduce transmission of antimicrobial resistant organisms, and to reduce overall infection rates. Approved hand hygiene methods: ...If hands are not visibly soiled, use an alcohol based hand rub for routinely decontamination of hands... Wash hands before having direct contact with patients... Wash hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. Wash hands after removing gloves Fingernails will be kept short, clean and healthy. If worn, polish should not be chipped. AORN Guidelines Essentials: Key Takeaways-Hand Hygiene Maintaining short fingernails (no longer than two mm [millimeters]) reduces the risk of harboring pathogens under fingernails, puncturing gloves or injuring patients... Artificial fingernails or extenders should not be worn in the perioperative setting because artificial nails have been associated with hand contamination and epidemiologically implicated in outbreak caused by gram-negative bacteria and yeasts... An observation of processing of instruments was conducted on 4/9/2025 at 10:07 AM with Employee Identifier (EI) # 7, Sterile Processing Technician (Tech)/Eye Coordinator and EI # 8, Certified Sterile Processing Tech. EI # 7 removed PPE (personal protective equipment) and failed to perform hand hygiene before donning gloves to continue with processing instruments. EI # 7's nails were extended beyond his/her fingertips. EI # 8 donned gloves, without performing hand hygiene to arrange and package eye instruments into a rigid container. The gloves were removed and hand hygiene was not performed. EI # 8's nails extended several mm's from his/her fingertips and appeared to show several mm's of natural nail growth from his/her nailbed not covered by the artificial nail. An interview was conducted with EI # 1, CEO (Chief Operating Officer), on 4/10/25 at 10:25 AM who confirmed hand hygiene was not performed per facility policy. |