Initial Comments:
This report is the result of an unannounced onsite complaint investigation (CHL24C177S) completed on-site on March 15, 2024, and off-site on March 21, 2024, at Geisinger - Community Medical Center. It was determined that the facility was not in compliance with the requirements of the Pennsylvania Department of Health's Rules and Regulations for Hospitals, 28 PA Code, Part IV, Subparts A and B, November 1987, as amended June 1998.
Plan of Correction:
149.13 LICENSURE
PREVENTION OF TRANSMISSION OF PATHOGENS
Name - Component - 00
149.13 Prevention of transmission of
pathogens.
There shall be written policies
and procedures to prevent indirect and
direct transmission of pathogens or
other toxic substances with materials
issued from the central supply.
service.
Observations:
Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to ensure staff working in the decontamination room followed infection control measures to prevent the transmission of pathogens for one of three staff observations in the decontamination room (EMP17).
Findings include:
Review on March 15, 2024, of the facility's "Hand Hygiene" policy, last revised January 10, 2024, revealed "Purpose The infection control hand hygiene policy is utilized to reduce the transmission of organisms to patients, visitors, and employees ...Policy The Infection Control Hand Hygiene Policy: 1. Geisinger administration and staff recognize the potential hazards facing patient and healthcare workers related to healthcare associated infections. 2. Defines infection prevention practices and products (soaps, hand sanitizers and lotions) that will ensure the safety of patients, employees, and visitors by minimizing the risk of acquisition and transmission of healthcare associated infections. 3. Complies with regulatory and accreditation requirements related to the prevention of infections ..."
Observation on March 15, 2024, at 1115 revealed EMP17 disassembling contaminated surgical containers. EMP17 placed a contaminated surgical instrument in the sink, and with the contaminated gloved left hand, reached up under the protective face shield and adjusted the eyeglasses and the face mask. EMP17 then returned to cleaning the contaminated surgical instrument.
Interview with EMP1 on March 15, 2024, at the time of the observation confirmed this finding.
Plan of Correction:POLICY:
The policy, "Hand Hygiene", was reviewed by the System Director of Infection Control, AVP of Nursing – Surgical Services, Manager of Central Sterile and Surgical Suite and the Regulatory Performance Coordinator and determined no revisions are needed. The policy was last reviewed on 2/15/24 and approved 3/5/24.
All Central Sterile Processing (CSP) staff will be re-educated by the manager of Central Sterile and Surgical Suite or designee on the "Hand Hygiene" policy as evidenced by sign in sheets by 4/22/24.
EMP17 had 1:1 verbal coaching session regarding "Hand Hygiene" policy on 3/21/24.
MONITORING:
Starting 4/22/24, weekly observations of the Decontamination area will be completed on all shifts for 3 consecutive months of 100% compliance. Random observational tracers will be conducted to ensure on-going compliance.
Repeat offenders will be addressed on a 1:1 basis by the Manager of Central Sterile/Surgical Suite/AVP nursing – Surgical Services up to and including disciplinary actions.
The data will be shared at monthly staff meetings, and the findings will be forwarded to the Regulatory Performance Improvement Department for review and reported to the Performance Improvement Committee as applicable.
RESPONSIBILITY:
The AVP of Nursing Services.
149.14 LICENSURE
CENTRAL SUPPLY EDUCATION PROGRAM
Name - Component - 00
149.14 Central supply service
education programs.
Although initial orientation of
employes in the central supply service
should be sufficient to enable them to
carry out the tasks outlined in their
job descriptions, they should have
further on the job training and
continuing education in areas of
asepsis and other pertinent topics
applicable to services rendered by the
services.
Observations:
Based on review of facility documents, personnel files (PF) and staff interview (EMP), it was determined the facility failed to ensure staff working in the Central Sterile Processing Department received training on the Censitrac system for six of 22 personnel files reviewed (PF4, PF8, PF9, PF13, PF18 and PF19).
Findings include:
Review on March 15, 2024, of the facility's "CEP/Preceptor Check-off List (Continuing Education / Certification Folder)" dated October 2019, revealed "Department Tour Communication: ... logging into Censitrac ... Decontamination Area: ... Checking Censitrac screen for instructions/pictures/messages ...Entering Quality Feedback (show choices in Censitrac ... Assembly Area: ... Censitrac software (logging-in, scan points, count sheets, instructions/pictures, One Source) ... Quality checks for instrumentation: Disassembly/reassembly for sterilization (refer to Censitrac instructions and pictures) ... Steam Sterilization: ...How to issue a recall in Censitrac if necessary to retrieve items ...Cycle selections: Censitrac instruction, explanation of V-pro cycles (be careful when selecting cycle ...Sterrad: Resulting load in Censitrac, signing & scanning load tape ...How to issue a recall in Censitrac if necessary to retrieve items ... Clinic Assignment: Processing Assembles sets/trays according to Censitrac instructions ..."
Phone interview with EMP3 on March 21, 2024, at 1345 revealed the facility does not have Censitrac instructions.
Review of PF4 on March 15, 2024, revealed this Central Sterile Processing employee was hired on July 11, 2022. There was no documentation in PF4 indicating this employee received training on the Censitrac system at the time of orientation or at any time from the date of hire to March 15, 2024.
Review of PF8 on March 15, 2024, revealed this Central Sterile Processing employee was hired on October 17, 2022. There was no documentation in PF8 indicating this employee received training on the Censitrac system at the time of orientation or at any time from the date of hire to March 15, 2024.
Review of PF9 on March 15, 2024, revealed this Central Sterile Processing employee was hired on February 5, 2018. There was no documentation in PF9 indicating this employee received training on the Censitrac system at the time of orientation or at any time from the date of hire to March 15, 2024.
Review of PF13 on March 15, 2024, revealed this Central Sterile Processing employee was hired on December 7, 2015. There was no documentation in PF13 indicating this employee received training on the Censitrac system at the time of orientation or at any time from the date of hire to March 15, 2024.
Review of PF18 on March 15, 2024, revealed this Central Sterile Processing employee was hired on October 3, 2022. There was no documentation in PF18 indicating this employee received training on the Censitrac system at the time of orientation or at any time from the date of hire to March 15, 2024.
Review of PF19 on March 15, 2024, revealed this Central Sterile Processing employee was hired on March 21, 2022. There was no documentation in PF19 indicating this employee received training on the Censitrac system at the time of orientation or at any time from the date of hire to March 15, 2024.
Interview with EMP1 and EMP2 on March 15, 2024, at the time of the personnel file review confirmed the above findings.
Plan of Correction:POLICY:
The AVP of Nursing – Surgical Services, Manager of Central Sterile and Surgical Suite, Sterile Processing educator and the Performance Improvement Coordinator reviewed the CEP/preceptor check off list and identified educational opportunities to reinforce Censitrac education to Central Sterile Processing staff.
The Manager of Central Sterile and Surgical Suite collaborated with the vendor to provide self-guided web-based training modules on campus for all staff including PF4, PF8, PF9, PF13, PF18 and PF19, new employees, as a refresher or directed by department manager/designee as evidence by certificates/transcript of completion. All staff will complete this education by 4/22/24.
Monitoring:
Quarterly audits for compliance of Censitrac training modules will be completed to ensure compliance of needed education to new employees beginning 4/22/24.
Responsibility:
AVP nursing – surgical services
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