Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 670029 (X3) Date Survey Completed 03/15/2011
Name of Provider or Supplier First Surgical Hospital Street Address, City, State 4801 Bissonnet Blvd, Bellaire, TX
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)
A0747 INFECTION CONTROL
CFR(s): 482.42

The hospital must provide a sanitary environment to avoid sources and transmission of infections and communicable diseases. There must be an active program for the prevention, control, and investigation of infections and communicable diseases.


This CONDITION is not met as evidenced by:
Based on observation, interview, and record review the Hospital failed to ensure 3 of 7 out-patient emergency departments implemented quality controls for autoclaves. (St Michael's Sugar Land, St. Michaels Westheimer, and St. Michaels Woodlands) Findings include: Infection control activities at 3 out-patient emergency rooms were not integrated with the hospital. Three locations were using autoclaves without implementing quality controls. Observation 3/11/11 at 11:55 a.m. at St. Michaels Emergency center Woodlands revealed an autoclave in the laboratory room. Interview 3/11/11 at noon with the emergency room technician (ID# 49) revealed the autoclave is used to sterilize surgical instruments for suturing. The technician stated the center does not maintain logs of quality assurance testing for the autoclave and the center did not have a policy for operational standards, such as temperature monitoring or monthly spore testing. Observation 3/15/11 at 10:30 a.m. at St. Michaels Emergency center Westheimer revealed an autoclave in a storage room. Interview 3/15/11 at 10:35 a.m. with an emergency room technician (ID# 84) revealed the autoclave is used to sterilize surgical instruments for suturing. The technician stated the center does not maintain logs of quality assurance testing for the autoclave and the center did not have a policy for operational standards, such as temperature monitoring or monthly spore testing. Observation 3/11/11 at 3:00 p.m. at St. Michaels Emergency center Sugar Land revealed an autoclave in the laboratory room. Interview 3/11/11 at 3:15 p.m. with the nurse (ID# 48) on duty at St. Michaels Sugar Land revealed the autoclave is used to sterilize instruments for suturing. The nurse stated the center does not maintain logs of quality assurance testing for the autoclave. Record review of a hospital policy titled "Infection Control for Sterile Processing" dated 12/2009 stated "Sterilizer logs, chart / chemical / biological tests, and spore test shall be maintained as required......Recording charts and gauges: shall be examined by the sterilizer operator at the beginning and end of each cycle (temperature and pressure). Records shall be maintained per hospital / regulatory requirements." The Infection Control nurse (ID# 61) at the hospital stated she has never been to any of the out-patient emergency centers and was not aware the centers were using autoclaves to sterilize instruments. Record review of a policy titled "Surveillance" dated 1/12/2009 stated "Surveillance requires a constant flow of information to the Infection Control Practitioner. Information is usually acquired by: Rounds also ensure that environmental and engineering controls are in place and properly utilized."