Initial Comments:
This report is the result of a complaint investigation (CHL11C661A) conducted on May 24, 2011, at the American Women's Services. It was determined that the facility was in compliance with the requirements of the Pennsylvania Department of Health Regulations 28 Pa Code, Chapter 29, Subchapter D, Ambulatory Gynecological Surgery in Hospitals and Clinics.
Plan of Correction:
No POC Required STANDARD
Recommendation
Name - Component - 00
Observations:
Based on observations it was determined that American Women's Services failed to maintain a safe and sanitary environment.
Findings:
A tour of the facility was conducted on May 24, 2011, between 10:00 and approximately 10:20 AM. The following were observed:
1) Processing Room: Wrapped instrument packs identified as autoclaved in the same basket as unwrapped speculums.
Instruments incompletely submerged in a container of cleaning solution. Unwrapped instruments were noted in another uncovered container.
A plastic basin was noted to be in the sink containing a clear solution with some unknown particles in the solution. It was identified as the 28-day cleaning solution. It could not be determined when the solution should be discarded.
The "contents of conception" freezer which was over half full, was located in the room with the autoclaved instrument packs. By interview it was relayed that contents remained in the freezer for 3 months.
A needle from a syringe was found on the counter.
It was learned that pathology specimens had not been sent for examination for a two month period of time. Action had been taken with the responsible employee by the facility, but no tracking mechanism for specimens sent for pathological examination had been instituted to ensure the process is carried out.
2) Ultrasound/Procedure/Exam Room: Ceiling tiles with water marks and large brown stains. A ceiling tile directly over the exam table was loose. Behind the curtain on the outside wall of the room there were unprotected telephone wires.
3) Exam Room: Sharps container full to top of container.
4) Lab room: Medications stored in the refrigerator.
5) Office/Medication Storage Cabinet: Unknown substance in four predrawn syringes in the medication cabinet to be wasted. By interview it was determined that controlled substances that were not completely used were discarded without wasting in the sharps containers.
Uncovered phone outlet on the wall.
Wall of a column in the room was torn out to replace pipes and never replaced. Area was covered with surgical towels.
6) Recovery Area: Several brown bags sitting on top of the desk with14 Doxycyline in each bag.
7) Unqualified personnel: Office Manager performs ultrasounds and is not a technician.
RN in recovery area does not have current CPR certification.
Lack of documentation of infection control training for all staff.
8) Handwashing stations not conveniently located to promote handwashing between procedures and patients.
Plan of Correction:POC is optional and not required.
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