| Statement of Deficiencies | (X1) Provider/Supplier/CLIA Identification Number 01C0001000 | (X3) Date Survey Completed 11/16/2023 |
| Name of Provider or Supplier Montgomery Surgical Center Llc | Street Address, City, State 470 Taylor Road, Montgomery, 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) |
| Q0241 | SANITARY ENVIRONMENT CFR(s): 416.51(a) The ASC must provide a functional and sanitary environment for the provision of surgical services by adhering to professionally acceptable standards of practice. This STANDARD is not met as evidenced by: Based on observations, review of facility policies and procedures and staff interviews, it was determined the facility failed to ensure the staff: 1. Performed hand hygiene prior to donning gloves and after removing gloves. 2. Disinfected the medication vial septum prior to drawing up medication. 3. Disinfected the Intravenous (IV) port prior to injecting medication. 4. Wore gloves per facility policy and procedure. 5. Disposed of the fingerstick lancet after use in a puncture resistant container per facility policy and procedure. Findings include: Facility Policy: General Hand Hygiene Policy Number: None Date Reviewed: 1/23 Purpose To prevent/reduce the transmission of infectious agents from patient to employee and employee to patient. Policy All personnel shall practice general hand hygiene... Procedure A. Hand Hygiene should be performed in the following instances: Before and after patient contact Before performing a clean or sterile task such as starting an IV (intravenous) [access]...or surgical site prepping. After removing gloves... After risk for blood or body fluid exposure. ...or there is a possibility that there has been contact with blood or other potentially infectious materials. ...F. An alcohol-based hand rub may be used for routine decontamination of the hands. Facility Policy: Standard Precautions Policy Number: None Date Reviewed: 1/23 Purpose To identify practices that can be employed to protect patient and health care workers from exposure to bloodborne and body fluid pathogens... Policy Standard Precautions are implemented for every patient as the primary strategy for successful control of disease-producing micro-organisms... Procedure 1. Gloves are to be worn when handling blood or...anything contaminated with...blood... 2. Gloves are changed after contact with a patient...or contaminated items. Hands are washed as soon as gloves are removed or cleansed with an antimicrobial waterless solution. 3. Hand Hygiene should be performed after each contact with a patient...or contaminated items. 10. After use, syringes...blades, and other sharp items should be placed in a puncture resistance container for disposal...Sharps containers are located in all work areas where sharps are used. Facility Policy: Safe Injection, Infusion, and Medication Vial Practices Policy Number: None Date Reviewed: 1/23 Procedure: A. Aseptic Technique 1. Staff shall perform hand hygiene prior to accessing supplies, handling vials, and IV solutions, and preparing or administering medications and conducting point-of-care testing (e.g., blood glucose, coagulation studies) 2. Staff shall use aseptic technique in all aspects of parenteral medication administration, medication vial use, injections, and point-of-care testing. ...8. Disinfect the rubber stopper of medication vials...with sterile 70% (percent) alcohol before inserting a needle.... 10. Disinfect catheter hubs, needleless connectors, and injection ports before accessing...vigorously apply mechanical friction with...or sterile 70% isopropyl alcohol...swab.... ...C. IV solutions ...7. IV ports are disinfected using friction and 70% alcohol... ...F. Medication Vials ...6. Disinfect the rubber septum on all vials prior to each entry, even after initially removing the cap of a new unused vial. Facility Policy: Medication Administration Policy Number: None Date Reviewed: 1/21 Policy: To assist staff in the safe administration of medications ... ...11. Guidelines for routes for administration of medications. b. Intravenous injection. 1. Select injection port and cleanse with alcohol prep. 4. An observation of care, testing of an un-sampled patient's blood glucose, was conducted on 11/15/23 at 7:49 AM in the Post Acute Care Unit (PACU) Unit, Bay 8, with EI # 3, PACU, RN. EI # 3 retrieved the glucometer (a point of care device used to test capillary blood glucose levels) from the nurse station counter, and with ungloved hands cleaned the glucometer with a disinfecting cloth wipe. Without first performing hand hygiene, EI # 3 donned gloves, used a fingerstick lancet, obtained the blood sample onto the test strip, and tested the patient's blood glucose sample. EI # 3 then disposed of the fingerstick lancet into the trash and not the puncture resistant sharps container. EI # 3 failed to wear gloves when in contact with potentially contaminated items, failed to perform hand hygiene after cleaning equipment and before donning gloves, and failed to dispose of sharps into a puncture resistant container. An interview was conducted on 11/15/23 at 8:10 AM with EI # 1 who confirmed staff failed to follow the policy and procedure for hand hygiene, glove use, and sharps disposal. 1. An observation of care was conducted on 11/14/23 at 10:00 AM in Pre-op (Pre-Operative) bay 13 to observe staff prepare PI (Patient Identifier) # 12 for a Cataract Extraction with an Intraocular Lens Implant. At 10:15 AM, Employee Identifier (EI) # 4, Pre-op Nurse, without performing hand hygiene (HH), donned gloves and placed dilating gtts (drops) in the patient's right eye. Wearing the same pair of gloves, EI # 4 assembled and opened supplies to place the patient's IV catheter. After starting the IV, EI # 4 placed more dilating gtts into the patient's right eye wearing the same gloves used to start the IV. EI # 4 failed to change gloves, perform HH and re-glove between procedures. At 10:31 AM, EI # 4, without performing HH, donned gloves and applied more gtts to the patient's right eye. At 11:45 AM, the patient was in the OR (operating room) being prepared for surgery. EI # 5, CRNA (Certified Registered Nurse Anesthetist) removed gloves and without performing HH, donned gloves to tape the LMA (laryngeal mask airway) place. The gloves were removed and HH was not performed. At approximately 11:58 AM, EI # 6, Circulating Nurse, without performing HH, donned sterile gloves and prepped the patient's right eye for surgery. At approximately 12:23 PM, EI # 5, without performing HH, donned gloves and administered an IV medication. The gloves were removed and HH was not performed. At 12:33, the surgery was over. EI # 5, without performing HH, donned gloves to remove the patient's LMA and insert an oral airway. The gloves were removed and without performing HH another pair of gloves were donned.. An interview was conducted on 11/16/23 at 10:15 AM with EI # 1, Administrator, who confirmed the staff failed to perform HH according to the facility policy. 2. An observation of care was conducted for PI # 12 on 11/14/23 at 11:46 AM in OR (operating room) eight. EI # 6, circulating nurse, was observed preparing Xylocaine 1% (an anesthetic agent) for administration. EI # 6 failed to disinfect the vial's septum prior to allowing the scrub tech to withdraw the medication. An interview was conducted on 11/16/23 at 10:15 AM with EI # 1 who confirmed EI # 6 should have disinfected the vial's septum prior to allowing the scrub tech to draw from the vial. 3. An observation of care was conducted for PI # 12 on 11/14/23 at 12:07 PM in OR eight. EI # 5, CRNA, failed to disinfect the IV port prior to injecting Robinul 0.2 mg. An interview was conducted on 11/16/23 at 10:15 AM with EI # 1 who confirmed EI # 5 should have disinfected the IV port prior to injecting the Robinul. |