SFSD, as a contracted service with the CCSF-DPH, is a participant on the key hospital committees addressing campus safety & security issues:

Transcription

1 EC : EP 3, Tier 4, A, D, R (pg 55 of 86): The hospital has a written plan for managing the following: The environmental safety of patients and everyone else who enters the hospital's facilities. (See also EC , EP 15) EP 4, Tier 4, A, D, R (pg 55 of 86): The hospital has a written plan for managing the following: The security of everyone who enters the hospital's facilities. (See also EC , EP 15) Organization findings (pg 56 of 86): EP 3 There was not a written plan for managing the environment of care related to patient safety and everyone else who entered the hospital's facilities which addressed specific relevant issues. The plan that was reviewed was generic and non-specific with no information built in from the previous year's evaluation of the plan. Hospital leadership updated the SFGH Environment of Care Report to address the plan for managing the environment of care related to safety and to security including performance metrics. The revised report was approved by hospital leadership and the Governing Body Joint Conference Committee effective January Hospital leadership reviewed and revised the Environment of Care (EOC) Committee membership to ensure representation by appropriate staff, including SFSD staff, and to ensure committee reporting structure. SFSD, as a contracted service with the CCSF-DPH, is a participant on the key hospital committees addressing campus safety & security issues: 1. Administrative Operations Meeting 2. Bed Meetings 3. Critical Incident Response Team 4. Code Green Task Force (At-Risk Missing Patients) 5. Disaster Council Committee 6. Employee Health & Safety 7. Environment of Care (EOC) Committee 8. Hospital Leadership Security Meeting 9. Infant/Child Security Program Committee (Code Pink) 10. Management Forum 11. Violence Prevention Team Lann Wilder Kath Jung Tom Holton Capt. Farrigno KEY: Tier 3 - Direct impact Tier 4 - Indirect impact M Measure of Success () Page 1 of 65

2 Hospital and SFSD leadership reinforced the expectation that SFSD representatives attend and are actively involved on key hospital committees addressing campus safety and security issues and will verify SFSD representatives attendance at committee meetings. EP 4 There was not a written plan for managing the environment of care related to security which addressed specific relevant issues. The plan that was reviewed was generic and non-specific with no information built in from the previous year's evaluation of the plan. Hospital leadership updated the SFGH Environment of Care Report to address the plan for managing the environment of care related to safety and to security including performance metrics. The revised report was approved by hospital leadership and the Governing Body Joint Conference Committee effective January Lann Wilder Kath Jung Tom Holton Capt. Farrigno Hospital leadership reviewed and revised the Environment of Care (EOC) Committee membership to ensure representation by appropriate staff, including SFSD staff, and to ensure committee reporting structure. SFSD, as a contracted service with the CCSF-DPH, is a participant on the key hospital committees addressing campus safety & security issues: 1. Administrative Operations Meeting 2. Bed Meetings 3. Critical Incident Response Team 4. Code Green Task Force (At-Risk Missing Patients) 5. Disaster Council Committee 6. Employee Health & Safety 7. Environment of Care (EOC) Committee 8. Hospital Leadership Security Meeting 9. Infant/Child Security Program Committee (Code Pink) 10. Management Forum 11. Violence Prevention Team KEY: Tier 3 - Direct impact Tier 4 - Indirect impact M Measure of Success () Page 2 of 65

3 Hospital and SFSD leadership reinforced the expectation that SFSD representatives attend and are actively involved on key hospital committees addressing campus safety and security issues and will verify SFSD representatives attendance at committee meetings. EC , EP 1, Tier 4, A, R (pg 57 of 86): The hospital identifies safety and security risks associated with the environment of care that could affect patients, staff, and other people coming to the hospital's facilities. Note: Risks are identified from internal sources such as ongoing monitoring of the environment, results of root cause analyses, results of annual proactive risk assessments of high-risk processes, and from credible external sources such as Sentinel Event Alerts. (See also EC , EP 14) Organization findings (pg 58 of 86): EP 1 It was found that the sharps disposal box in a patient room on telemetry floor was found at a height/level where it could be reached into by a child EP 1 Room 4C34 used to be an office, but is now a treatment area on the Outpatient Infusion Center. The door has a key pad access. Patients in this room could be put at risk if someone could not enter the room if needed. EP 1 Zone 3 of MRI is not restricted screened area as defined by org. Law enforcement officer was seen in Zone 3 who as per org was not screened prior to entry to zone 3.Interview with lab aide who has access to zone 3 could not identify all MRI zones. The door to zone 4 was wide open during surveyor visit. SHARPS: Facilities staff raised the sharps disposal box in the patient room on the telemetry floor off of the floor and mounted it on the wall. KEY PAD: The Facility locksmith removed the keypad to Room4C34 replaced it with a regular key lock.,ri: Following the ICM survey, Radiology leadership took the following actions: *determined and established MRI safety zones as recommended by American College of Radiology (ACR) for MRI Safe Practices 2013; completed *established map of the MRI Safety Zones; completed *changed 02 tank to non- ferrous MRI safe tank; Completed Leslie Dubbin Leslie Dubbin Shermineh Jafarieh David Sostarich Ed Ochi KEY: Tier 3 - Direct impact Tier 4 - Indirect impact M Measure of Success () Page 3 of 65

4 *added temporary barrier device for Non-ferrous bright yellow chain between zone 2 and zone 3; completed *additional and proper signage added to areas to assure zone identification; completed *reviewed in house fire safety with the SFGH Fire Marshall; completed *Radiology Leadership to work with EOC to review MRI safety policies with CCSF Sheriff and Fire Department to ensure safety plan; complete by *revised and updated Department of Radiology MRI Safety Manual (Draft completed for review by EOC); *document will be finalized and approved by Radiology Department Leadership: by *Radiology Staff Education on Zone and Zone Safety to be completed by *relocate dressing area to Zone 2 from Zone 3; work order submitted to Facilities on *initiated staff screening tool for non-radiology staff that need to enter zone 3 or 4; completed on *move patient registration for MRI (previously in Zone 2) to Radiology Window 2 where only screening patients and staff will have access to Zone 2; to be completed by *add permanent barrier to entrance of Zone 3 to assure proper management of flow through this area; work order submitted to facilities KEY: Tier 3 - Direct impact Tier 4 - Indirect impact M Measure of Success () Page 4 of 65

5 *ensure hospital wide knowledge and training of MRI safety by inserting updated MRI safety policies in hospital continuing education (Halogen EOC module) and staff orientation (through DET); to be completed by EC , EP 1, Tier 3, C, R (pg 59 of 86): The hospital minimizes the potential harm from fire, smoke, and other products of combustion. Organization findings (pg. 59 of 86): EP1 Prevantix Maxiswabstix which is an alcohol based swab as per staff when asked about dry time was 60 seconds against manufacturers instructions of 90 seconds. Also further clarification with staff in intervention radiology area revealed that the dry time as specified by manufacturers instruction was not the norm. Following the ICM survey, Radiology Service implemented the following: "Educated IR staff re: proper use of Prevantix MaxiSwabstick via unit meetings and newsletters on ; each individual who performs prep is evaluated via return demonstration - completed "Placed laminated posters in each procedure room that show proper steps for use of prep stick; laminated posters hung on 1/13/2014. *IR staff who perform patient skin preparation will have 'proper skin prep" practice added to competency evaluation and it will be assessed on initial and annual competency checklist. Will monitor staff usage of Prevantix MaxiSwabstic weekly for a period of 1 month. Compliance will be reported as: Numerator: Number of IR procedure patients who had skin preparation completed correctly without intervention. Denominator: All IR procedure patients needing skin prep Goal: 100% compliance Elaine Dekker Lann Wilder Ed Ochi Kathy Jung Patty Coggan Kathy Ballou Shermineh Jafarieh David Sostarich Mark Wilson Numerator: Number of IR personnel observed who performed skin preparation correctly. KEY: Tier 3 - Direct impact Tier 4 - Indirect impact M Measure of Success () Page 5 of 65

6 Denominator: All IR personnel who are responsible for performing patient skin prep. Goal: 100% of personnel will have initial evaluation by the end of 1 month EC : EP 2, Tier 4, A, D (pg 60 of 86): The hospital maintains a written inventory of all operating components of utility systems or maintains a written inventory of selected operating components of utility systems based on risks for infection, occupant needs, and systems critical to patient care (including all life-support systems). The hospital evaluates new types of utility components before initial use to determine whether they should be included in the inventory. (See also EC , EPs 1, 3-5) EP 6, Tier 3, A, R (pg 61 of 86): In areas designed to control airborne contaminants (such as biological agents, gases, fumes, dust), the ventilation system provides appropriate pressure relationships, air-exchange rates, and filtration efficiencies. Note: Areas designed for control of airborne contaminants include spaces such as operating rooms, special procedure rooms, delivery rooms for patients diagnosed with or suspected of having airborne communicable diseases (for example, pulmonary or laryngeal tuberculosis), patients in "protective environment" rooms (for example, those receiving bone marrow transplants), laboratories, pharmacies, and sterile supply rooms. For further information, see Guidelines for Design and Construction of Health Care Facilities, 2010 edition, administered by the Facility Guidelines Institute and published by the American Society for Healthcare Engineering (ASHE). Organization findings (pg 62 of 86): EP 2 Noted that the inventory list for the monitoring of air ventilation did not include the Sterile Processing Department, soiled utility rooms, or the endoscopy decontamination area. These areas had not been monitored or tested for proper air ventilation and relationship. EP 6 Noted that 3 operating room suites had air exchanges tested to less than 12 exchanges per hour. SPD, soiled utility rooms, endoscopy decontam areas not included on inventory list for monitoring of air ventilation: Following the 1CM Survey, the Chief Engineer physically walked to every room in the main hospital to verify room usage and create inventory. Effective 1/7/2014, the Chief Engineer compiled the Air Pressure Relationship inventory for the Main Hospital, work order System set to generate an annual work order to verify room usage for air pressure relationships. 3 ORs ACH less than 12 exchanges per hr: Following the ICM survey, the Director of Facilities contacted the Joint Commission Standards Interpretation Group (SIG) on 12/12/13 for a consultation; on 12119/13, Kathy Jung Max Bunuan Elaine Dekker Lann Wilder Greg Chase Kathy Jung Max Bunuan Elaine Dekker Lann Wilder Greg Chase KEY: Tier 3 - Direct impact Tier 4 - Indirect impact M Measure of Success () Page 6 of 65

7 SIG directed him to contact the regional OSHPD office and check if they would accept the design standard at the time of permitting. The OSHPD consultant wrote reported that the 2010 California Mechanical Code (CMC) required a minimum of twelve (12) ACH for ORs if it is 100% outside air system. He stated that if the Joint Commission is asking for 15 ACH, they are probably applying ASHRAE Standard 170 of which only 3 ACH have to be OSA for a Class A OR. California does not adopt this standards. SFGH complies with the current CMC requirements. The Chief Engineer made air system adjustments and currently 1 OR is below the required 12 ACH. Need vendor assist to balance the air system and achieve the required 12 ACH for all ORs. Projected completion date, 2/28/2014, work order System set to generate an annual work order to verify required ACH in Ors. EC , EP 4, Tier 3, A, D, R (pg 62 of 86): The hospital Inspects, tests, and maintains the following: Infection control utility system components on the inventory. These activities are documented. (See also EC , EPs 2-4) Organization findings (pg 63 of 86): EP 4 Air flow in the endoscope cleaning room was found positive by tissue test which was confirmed by differential pressure monitor. It was confirmed with facilities management that air exchanges were not conducted at this area since they were not included in the inventory. Effective 12/19/13, the Chief Engineer adjusted the air pressure relationship in the endoscopy cleaning room room is now negative compared to the corridor, work order Effective 1/7/14, the Chief Engineer created the Air Pressure Relationship inventory for the main hospital, work order System is set to generate an annual work order to verify room usage for air pressure relationships. Max Bunuan Kathy Jung Lann Wilder Greg Chase Ditas Hernandez EC , EP 3, Tier 4, A (pg 64 of 86): The hospital makes main supply valves and area shutoff valves for piped medical gas and vacuum systems accessible and clearly identifies what the valves control. KEY: Tier 3 - Direct impact Tier 4 - Indirect impact M Measure of Success () Page 7 of 65

8 Organization findings (pg 64 of 86): EP 3 Noted that an oxygen shut-off valve located in the anesthesia work room was obstructed by a supply cart and shelving for supplies. OXYGEN SHUT-OFF VALVE: Effective 12119/13, the Chief Engineer met with staff in affected areas to clear obstructions from the immediate area in front of 02 shutoff valves. Work order submitted to manufacture appropriate signage for 02 shutoff valves - work order Anticipate posting signage by 2128/2014. Compliance with requirement that 02 shutoff valves are not blacked to be verified via EOC rounds. Kathy Jung Max Bunuan Rich Elliot Greg Chase Lann Wilder Kathy Ballou Kyra Quon The Anesthesia Workroom Manager created a clearance area with tape on the floor below the shut-off valve to identify the floor space in front of the shut-off valve which should not be obstructed by carts. Removal of shelves around the shut-off valve, and taping of clearance space on floor below the valve, will ensure that the area is not blocked in any way. Reeducation and reminders will be sent out to anesthesia staff If area in front of valve is found blocked by storage/carts. Anything found blocking the shutoff valve will be removed immediately and staff reeducated about the policy. EP 3 Noted that a medical gas shut-off valve located in a C- Section OR room was obstructed by a trash receptacle. MEDICAL GAS SHUT-OFF Effective 12/19113, the Chief Engineer met with staff in affected areas to clear obstructions from the immediate area in front of 02 shutoff valves. Work order submitted to manufacture appropriate signage for 02 shutoff valves - work order Anticipate posting signage by 2/28/2014. Compliance with requirement that 02 shutoff valves are not blocked to be verified via EOC rounds. Kathy Jung Max Bunuan Rich Elliot Greg Chase Lann Wilder Kathy Ballou Kyra Quon EC : EP 1, Tier 4, C, R, M (pg 66 of 86): Interior spaces meet the needs of the patient population and are safe and suitable to the care, treatment, and services provided. EP 20, Tier 3, C, R, M: Areas used by patients are clean and free of offensive odors. KEY: Tier 3 - Direct impact Tier 4 - Indirect impact M Measure of Success () Page 8 of 65

9 Organization findings (pg 67 of 86): EP 1 It was found that the light fixture screen in the ceiling in cardiac cath area was found with a large stain suggesting by the color of a water stain LIGHT FIXTURE STAIN: Facilities staff cleaned light fixture diffuser, work order , completed 12/10/2013. The following EPs will be monitored monthly for four consecutive months via EOC rounds: EP1 M (light fixture stain) EP1 M (dust on Omnicell cabinet) EP1 M (broken, dirty blinds in 4C Infusion Center & 5A) EP1 M (hole in ceiling 4F34) EP1 M (no monolithic ceiling in acute psych unit) EP1 M (exposed plumbing in PES creating suicide risk) EP1 M (exposed plumbing in acute Psych units creating suicide risk) EP1 M (in dialysis - old floors, limited access to valves & water tx controls in water room, risk for cross contamination, potential to need blankets to transport pts during fire evacuation due to stairs not tested) Kathy Jung Francisco Saenz Max Bunuan Greg Chase Lann Wilder Elaine Dekker Sarah Doernberg Lisa Winston EP 1 Thick layer of dust was found over the top of Omnicell in the cardiac cath room DUST ON OMNICEL CABINET: Environmental Services removed the thick layer of dust from the top of the Omnicell on 12/10/2013. The following EPs will be monitored monthly for four consecutive months via EOC rounds: EP1 M (light fixture stain) EP1 M (dust on Omnicell cabinet) EP1 M (broken, dirty blinds in 4C Infusion Center & 5A) EP1 M (hole in ceiling 4F34) EP1 M (no monolithic ceiling in acute psych unit) EP1 M (exposed plumbing in PES creating suicide risk) EP1 M (exposed plumbing in acute Psych units creating Kathy Jung Francisco Saenz Max Bunuan Greg Chase Lann Wilder Elaine Dekker Sarah Doernberg Lisa Winston KEY: Tier 3 - Direct impact Tier 4 - Indirect impact M Measure of Success () Page 9 of 65

10 suicide risk) EP1 M (in dialysis - old floors, limited access to valves & water tx controls in water room, risk for cross contamination, potential to need blankets to transport pts during fire evacuation due to stairs not tested) EP 1 Blinds in the Outpatient Infusion Center and in the lounge on 5A were broken. This was both unsightly and a potential safety risk. BROKEN BLINDS: Facilities staff removed and replaced the broken blinds from 4C Infusion Center and 5A Solarium/room 5A24 - work order ; completed 1/13/2014. The following EPs will be monitored monthly for four consecutive months via EOC rounds: EP1 M (light fixture stain) EP1 M (dust on Omnicell cabinet) EP1 M (broken, dirty blinds in 4C Infusion Center & 5A) EP1 M (hole in ceiling 4F34) EP1 M (no monolithic ceiling in acute psych unit) EP1 M (exposed plumbing in PES creating suicide risk) EP1 M (exposed plumbing in acute Psych units creating suicide risk) EP1 M (in dialysis - old floors, limited access to valves & water tx controls in water room, risk for cross contamination, potential to need blankets to transport pts during fire evacuation due to stairs not tested) Kathy Jung Francisco Saenz Max Bunuan Greg Chase Lann Wilder Elaine Dekker Sarah Doernberg Lisa Winston Organization findings (pg 67 of 86): [CONTINUED] EP 1 There was a hole in a ceiling tile in room 4F34 (a clean storage area for respiratory therapy supplies). HOLE IN CEILING: Facilities staff replaced damaged ceiling tiles in room 4F34, work order , completed 12/20/2013. The following EPs will be monitored monthly for four consecutive months via EOC rounds: EP1 M (light fixture stain) Kathy Jung Francisco Saenz Max Bunuan Greg Chase Lann Wilder Elaine Dekker Sarah Doernberg Lisa Winston KEY: Tier 3 - Direct impact Tier 4 - Indirect impact M Measure of Success () Page 10 of 65

11 EP1 M (dust on Omnicell cabinet) EP1 M (broken, dirty blinds in 4C Infusion Center & 5A) EP1 M (hole in ceiling 4F34) EP1 M (no monolithic ceiling in acute psych unit) EP1 M (exposed plumbing in PES creating suicide risk) EP1 M (exposed plumbing in acute Psych units creating suicide risk) EP1 M (in dialysis - old floors, limited access to valves & water tx controls in water room, risk for cross contamination, potential to need blankets to transport pts during fire evacuation due to stairs not tested) EP 1 The acute psychiatric inpatient unit does not have monolithic ceiling which presents a risk for patients getting into the ceiling and have access to serious hazards. It also creates an opportunity for hiding contraband. MONOLITHIC CEILING: Changing the splined ceilings to monolithic ceilings requires an OSHPD project permit. Earliest estimated completion date is 9/30/2014. The following EPs will be monitored monthly for four consecutive months via EOC rounds: EP1 M (light fixture stain) EP1 M (dust on Omnicell cabinet) EP1 M (broken, dirty blinds in 4C Infusion Center & 5A) EP1 M (hole in ceiling 4F34) EP1 M (no monolithic ceiling in acute psych unit) EP1 M (exposed plumbing in PES creating suicide risk) EP1 M (exposed plumbing in acute Psych units creating suicide risk) EP1 M (in dialysis - old floors, limited access to valves & water tx controls in water room, risk for cross contamination, potential to need blankets to transport pts during fire evacuation due to stairs not tested) Kathy Jung Francisco Saenz Max Bunuan Greg Chase Lann Wilder Elaine Dekker Sarah Doernberg Lisa Winston EP 1 During a tour of the Psychiatric Emergency Service it was noted that there is exposed toilet plumbing as well as EXPOSED PLUMBING (PES): Facilities staff submitted work order to purchase and install suicide prevention plumbing Kathy Jung Francisco Saenz KEY: Tier 3 - Direct impact Tier 4 - Indirect impact M Measure of Success () Page 11 of 65

12 sink faucets and spouts which allow for looping of materials that could create a suicide risk. covers. Estimated completion date 2/28/2014, work order The following EPs will be monitored monthly for four consecutive months via EOC rounds: EP1 M (light fixture stain) EP1 M (dust on Omnicell cabinet) EP1 M (broken, dirty blinds in 4C Infusion Center & 5A) EP1 M (hole in ceiling 4F34) EP1 M (no monolithic ceiling in acute psych unit) EP1 M (exposed plumbing in PES creating suicide risk) EP1 M (exposed plumbing in acute Psych units creating suicide risk) EP1 M (in dialysis - old floors, limited access to valves & water tx controls in water room, risk for cross contamination, potential to need blankets to transport pts during fire evacuation due to stairs not tested) Max Bunuan Greg Chase Lann Wilder Elaine Dekker Sarah Doernberg Lisa Winston Organization findings (pg 67 of 86): [CONTINUED] EP 1 During a tour of the Psychiatric Inpatient Units it was noted that there is exposed toilet plumbing as well as sink faucets and spouts (in multiple bathrooms) which allow for looping of materials that could create a suicide risk. EXPOSED PLUMBING (INPT. UNIT): Facilities staff submitted work order to purchase and install suicide prevention plumbing covers. Estimated completion date 2/28/2014, work order The following EPs will be monitored monthly for four consecutive months via EOC rounds: EP1 M (light fixture stain) EP1 M (dust on Omnicell cabinet) EP1 M (broken, dirty blinds in 4C Infusion Center & 5A) EP1 M (hole in ceiling 4F34) EP1 M (no monolithic ceiling in acute psych unit) EP1 M (exposed plumbing in PES creating suicide risk) EP1 M (exposed plumbing in acute Psych units creating suicide risk) Kathy Jung Francisco Saenz Max Bunuan Greg Chase Lann Wilder Elaine Dekker Sarah Doernberg Lisa Winston KEY: Tier 3 - Direct impact Tier 4 - Indirect impact M Measure of Success () Page 12 of 65

13 EP1 M (in dialysis - old floors, limited access to valves & water tx controls in water room, risk for cross contamination, potential to need blankets to transport pts during fire evacuation due to stairs not tested) EP 20 During a tour of the Psychiatric Emergency Service it was noted that there was strong odor of urine in a vacant seclusion room. URINE ODOR: Environmental Services removed the strong urine odor in PES seclusion room on 12/10/2013. The following EPs will be monitored monthly for four consecutive months via EOC rounds: EP1 M (light fixture stain) EP1 M (dust on Omnicell cabinet) EP1 M (broken, dirty blinds in 4C Infusion Center & 5A) EP1 M (hole in ceiling 4F34) EP1 M (no monolithic ceiling in acute psych unit) EP1 M (exposed plumbing in PES creating suicide risk) EP1 M (exposed plumbing in acute Psych units creating suicide risk) EP1 M (in dialysis - old floors, limited access to valves & water tx controls in water room, risk for cross contamination, potential to need blankets to transport pts during fire evacuation due to stairs not tested) Kathy Jung Francisco Saenz Max Bunuan Greg Chase Lann Wilder Elaine Dekker Sarah Doernberg Lisa Winston EP 1 Noted in the dialysis unit that the floors were very old and very difficult to clean. The water room was very small and there was limited ability to access valves and water treatment controls. Due to the physical constraints within the patient care area there was high risk for crosscontamination of infection control concerns. In addition, fire evacuation routes involved numerous flights of stairs and the mode of patient evacuation may require the use of blankets. This method of evacuation had never been tested. The organization stated that there were numerous identified building code noncompliance issues. DIALYSIS: The building where the Renal Service Outpatient Chronic Dialysis unit is located is close to one hundred years old. Hospital leadership has been in process of reviewing relocation options; this is a long-term project - recommendations are under review. The Chief Engineer met with the Renal Service Outpatient Chronic Dialysis unit leadership to formulate a plan for floor repair; estimated completion date is 3/14/2014. The Infection Control Program Manager met with Renal Service Outpatient chronic Dialysis unit leadership staff to review infection control practices to prevent cross-contamination. The SFGH Kathy Jung Max Bunuan Elaine Dekker Leslie Dubbin KEY: Tier 3 - Direct impact Tier 4 - Indirect impact M Measure of Success () Page 13 of 65

14 Fire Marshall and the SFGH Disaster Coordinator will meet with Renal Service Outpatient Chronic Dialysis leadership to develop simulation evacuation drill and schedule accordingly. The following EPs will be monitored monthly for four consecutive months via EOC rounds: EP1 M (light fixture stain) EP1 M (dust on Omnicell cabinet) EP1 M (broken, dirty blinds in 4C Infusion Center & 5A) EP1 M (hole in ceiling 4F34) EP1 M (no monolithic ceiling in acute psych unit) EP1 M (exposed plumbing in PES creating suicide risk) EP1 M (exposed plumbing in acute Psych units creating suicide risk) EP1 M (in dialysis - old floors, limited access to valves & water tx controls in water room, risk for cross contamination, potential to need blankets to transport pts during fire evacuation due to stairs not tested) EC , EP 15, Tier 3, A, R (pg 69 of 86): Every 12 months, the hospital evaluates each environment of care management plan, including a review of the plan's objectives, scope, performance, and effectiveness. (See also EC , EPs 3-8; EC , EP 1) Organization findings (pg 69 of 86): EP 15 There was no documentation of the evaluation for each of the environment of care management plans. Hospital leadership updated the SFGH Environment of Care Report. Hospital leadership restructured the Environment of Care Committee as a multidisciplinary leadership committee with representatives from Nursing, Infection Control, Clinical Laboratory, Pharmacy, Environmental Services, and Quality Management. Membership includes program managers for each of the six EOC management programs: Safety, Security, Hazardous Materials & Waste, Medical Equipment, Utilities & Fire Life Safety, and Emergency Management. The EOC Kathy Jung Lann Wilder Tom Holton KEY: Tier 3 - Direct impact Tier 4 - Indirect impact M Measure of Success () Page 14 of 65

15 Committee is now co-chaired by the Associate Administrator for Support Services and the Patient Safety Officer. The EOC Committee reports quarterly to the hospital-wide Quality Council. The EOC Committee is charged with developing additional performance metrics and tracking mechanisms to more effectively capture key information to be included in the annual evaluation of the EOC management plans. HR , EP 5, Tier 4, C, D, R, M (pg 70 of 86): Staff comply with applicable health screening as required by law and regulation or hospital policy. Health screening compliance is documented. Organization findings (pg 70 of 86): EP 5 The personnel file of an RN who recently returned from a one year LOA was reviewed. It was noted that she did not have a fit test done, even though she was due for annual fit testing. It was further identified that Employee Health staff are not notified when a staff member returns from an LOA so that any required health screening can be completed. The Employee Health Service (EHS), in collaboration with Environmental Health and Safety and Infection Control, has drafted a matrix to identify employees working on the SFGH campus who are required to be fit tested for a N95 Respirator. Annual Fit Testing will be conducted for each work area where staff are identified in the matrix as requiring respirators. The fit testing the same month as the work area's annual TB surveillance. Respirator Fit Testing compliance will be included on the monthly OHS report that is compiled for TB surveillance statistics. It will be the manager's responsibility to ensure that all employees identified in the matrix as requiring respirators are compliant with Fit Testing. The manager will notify EHS when an employee returns from a leave of absence or is in an As Needed status such as a P103 and is not current with their Fit Testing. Ron Weigelt Leslie Dubbin Tom Holton Aiyana Johnson Ed Ochi Maggie Rykowski EHS staff will collaborate with UCSF Employee Health to develop a mechanism to ensure the identification of UC KEY: Tier 3 - Direct impact Tier 4 - Indirect impact M Measure of Success () Page 15 of 65

16 employees working on the SFGH campus and their compliance with annual fit testing. : The Director of Occupational Health or designee(s) will monitor compliance with requirements to be fit tested with an N95 respirator for four consecutive months. Numerator: the number of staff compliant with annual N95 fit testing. Denominator: the number of employees required to be fit tested for a N95 respirator. The OHS N95 Fit Testing & TB Surveillance results will be reported monthly for one quarter to Infection Control Committee and to the Accreditation, Licensing, Certification Committee (ALCC). The N95 Fit Testing and TB Surveillance compliance data will be included in the Infection Control Committee annual report to Quality Council. EP 5 Noted during personnel file review that a 'fit test' had not been conducted for an anesthesia technician during 2012 and 2013 per organizational policy. The Employee Health Service (EHS), in collaboration with Environmental Health and Safety and Infection Control, has drafted a matrix to identify employees working on the SFGH campus who are required to be fit tested for a N95 Respirator. Annual Fit Testing will be conducted for each work area where staff are identified in the matrix as requiring respirators. The fit testing the same month as the work area's annual TB surveillance. Respirator Fit Testing compliance will be included on the monthly OHS report that is compiled for TB surveillance statistics. Ron Weigelt Leslie Dubbin Tom Holton Aiyana Johnson Ed Ochi Maggie Rykowski It will be the manager's responsibility to ensure that all KEY: Tier 3 - Direct impact Tier 4 - Indirect impact M Measure of Success () Page 16 of 65

17 employees identified in the matrix as requiring respirators are compliant with Fit Testing. The manager will notify EHS when an employee returns from a leave of absence or is in an As Needed status such as a P103 and is not current with their Fit Testing. EHS staff will collaborate with UCSF Employee Health to develop a mechanism to ensure the identification of UC employees working on the SFGH campus and their compliance with annual fit testing. : The Director of Occupational Health or designee(s) will monitor compliance with requirements to be fit tested with an N95 respirator for four consecutive months. Numerator: the number of staff compliant with annual N95 fit testing. Denominator: the number of employees required to be fit tested for a N95 respirator. The OHS N95 Fit Testing & TB Surveillance results will be reported monthly for one quarter to Infection Control Committee and to the Accreditation, Licensing, Certification Committee (ALCC). The N95 Fit Testing and TB Surveillance compliance data will be included in the Infection Control Committee annual report to Quality Council. EP 5 Noted during HR file review of an ED RN that a fit test that was due in Feb 2013 was not done. The Employee Health Service (EHS), in collaboration with Environmental Health and Safety and Infection Control, has drafted a matrix to identify employees working on the SFGH campus who are required to be fit tested for a N95 Respirator. Ron Weigelt Leslie Dubbin Tom Holton Aiyana Johnson Ed Ochi KEY: Tier 3 - Direct impact Tier 4 - Indirect impact M Measure of Success () Page 17 of 65

18 Annual Fit Testing will be conducted for each work area where staff are identified in the matrix as requiring respirators. The fit testing the same month as the work area's annual TB surveillance. Respirator Fit Testing compliance will be included on the monthly OHS report that is compiled for TB surveillance statistics. Maggie Rykowski It will be the manager's responsibility to ensure that all employees identified in the matrix as requiring respirators are compliant with Fit Testing. The manager will notify EHS when an employee returns from a leave of absence or is in an As Needed status such as a P103 and is not current with their Fit Testing. EHS staff will collaborate with UCSF Employee Health to develop a mechanism to ensure the identification of UC employees working on the SFGH campus and their compliance with annual fit testing. : The Director of Occupational Health or designee(s) will monitor compliance with requirements to be fit tested with an N95 respirator for four consecutive months. Numerator: the number of staff compliant with annual N95 fit testing. Denominator: the number of employees required to be fit tested for a N95 respirator. The OHS N95 Fit Testing & TB Surveillance results will be reported monthly for one quarter to Infection Control Committee and to the Accreditation, Licensing, Certification Committee (ALCC). The N95 Fit Testing and TB Surveillance compliance data will be included in the Infection Control KEY: Tier 3 - Direct impact Tier 4 - Indirect impact M Measure of Success () Page 18 of 65

19 Committee annual report to Quality Council. HR , EP 4, Tier 4, C, D, R, M (pg 71 of 86): The hospital orients staff on the following: Their specific job duties, including those related to infection prevention and control and assessing and managing' pain. Completion of this orientation is documented. (See also 1C , EP 6; IC , EP 7; 1C , EP 2; RI , EP 8). Organization findings (pg 71 of 86): EP 4 Noted that initial orientation and competence assessment related to high level disinfection and the recertification method of disinfection was not documented in an individual's competence file. Noted that initial orientation and competence assessment related to the high level disinfection process and use of the Steris equipment for endoscopic equipment was not documented in the competence file of a registered nurse who was involved in the cleaning, decontamination, and reprocessing of the equipment. During the review of an RN file, it was noted GC, it was noted that the initial orientation to specific job duties was incomplete. DISINFECTION COMPETENCIES: The managers of units/work areas where employees perform high level disinfection processes and the Recertification method of disinfection (cleaning, decontamination, and re-processing of medical equipment) will review and revise their employee initial and annual skills/competency checklists to ensure that these skills/competencies are included on the checklists. The managers will then re-assess and evaluate all employees who perform high level disinfection processes and the Recertification method of disinfection (cleaning, decontamination, and re-processing of medical equipment) and document their assessment/evaluation using the revised employee initial and annual skills/competency checklists and submit the completed revised checklists to HR for inclusion in the employee HR file. INCOMPLETE INITIAL ORIENTATION: The Nurse Manager of the unit where the finding occurred will, in collaboration with HR, review the unit's new hire employee files from the past twelve months to ensure that the initial orientation performance evaluations, including skills/competency checklist, are complete and correct any initial orientation performance evaluations, including skills/competency checklists, found to be incomplete. 100% Ron Weigelt Leslie Dubbin Tom Holton Aiyana Johnson Ed Ochi Gillian Otway : DISINFECTION COMPETENCIES: The managers of units/work areas where employees perform high level disinfection processes and the Recertification method of disinfection will KEY: Tier 3 - Direct impact Tier 4 - Indirect impact M Measure of Success () Page 19 of 65

20 re-asses employee skills/competencies to perform these processes and ensure that documentation of the evaluation is complete. Numerator: the number of employees with high level disinfection competencies documented Denominator: the number of employees who perform high level disinfection INCOMPLETE INITIAL ORIENTATION: The Nurse Manager of the unit where the finding occurred will, in collaboration with HR, review the unit's new hire employee files from the past twelve months to ensure that the initial orientation performance evaluations, including skills/competency checklist, are complete and correct any initial orientation evaluations, including skills/competency checklists, found to be incomplete. Numerator: the number of unit new hire employees with complete initial orientation performance evaluations Denominator: all unit new hire employees IC : EP 1, Tier 4, C, R (pg 45 of 86): The hospital implements its infection prevention and control activities, including surveillance, to minimize, reduce, or eliminate the risk of infection. EP 2, Tier 3, C, M (pg 46 of 86): The hospital uses standard precautions, ' including the use of personal protective equipment, to reduce the risk of infection. Note: Standard precautions are infection prevention and control measures to protect against possible exposure to infectious agents. These precautions are general and applicable to all patients. Footnote *: For further information regarding standard precautions, refer to the website of the Centers for Disease Control and Prevention (CDC) at (Infection Control in Healthcare Settings). KEY: Tier 3 - Direct impact Tier 4 - Indirect impact M Measure of Success () Page 20 of 65

21 Organization findings (pg 46 of 86): EP.1: Obs. 1. During a tour of 7B three used bars of soap were found mixed together on the soap holder in a patient shower creating a potential infection control risk. EP1, Obs 1; 7B BAR SOAP: Effective 1/2/2014, the Dept of Psychiatry stopped ordering bar soap and replaced with individual bottle of body wash for patient use. Effective 11/2013, a hospital task force began studying alternatives to bar soap including replacement with single serving packets of liquid soap (short-term) and wall mounted soap dispensers in patient showers (long-term); product evaluation completed and Coloplast product selected. Materials Management placed in PMM inventory 1/6/2014. Memo sent to Nurse Manager staff 1/14/2014 announcing change. Nurse Manager or designee will conduct weekly EOC rounds to assess for on-going compliance with individual bottles in shower room. Elaine Dekker Kathy Jung Leslie Dubbin Kathy Ballou Francisco Saenz Sarah Doernberg Kathy Ballou Nela Ponferrada Sharon Kwong Jennie Farr Organization findings (pg 46 of 86): [CONTINUED] Obs. 2. During a tour of 7B the patient clothes washer was observed to have a collection soap and other debris on the around the soap dispenser and other areas indicating that the schedule for cleaning the washing machine is not being followed. EP1, Obs 2; 7B CLOTHES WASHER: Effective 1/4/2014, the Director of EVS clarified with EVS staff that cleaning laundry room includes wiping the exterior of machines and the interior of machine lids and added these items to the EVS cleaning checklist. Nurse Manager or designee will conduct weekly EOC rounds to assess for on-going compliance with washer/dryer cleanliness. Elaine Dekker Kathy Jung Leslie Dubbin Kathy Ballou Francisco Saenz Sarah Doernberg Kathy Ballou Nela Ponferrada Sharon Kwong Jennie Farr Observations 3 and 4. During a tour, it was noted that a stretcher located outside of 4D had a crack in the mattress. This could expose a patient to blood and body fluids. It was also noted on 5E that a drainage bag was touching the floor. This is not permitted by policy. EP1, Obs 3 & 4; 4D MATRESS & 5E BAG: Beginning 1/13/14, the Infection Control Program Manager is meeting with representatives from each department that owns gurneys to re-educate them regarding the established formal processes for scheduling inspections and requesting repair/replacement as needed. Facility Management is designated primary responsibility for storage and replacement of new mattresses. Educated owning areas to visually inspect gurney mattresses with every cleaning and Elaine Dekker Kathy Jung Leslie Dubbin Kathy Ballou Francisco Saenz Sarah Doernberg Kathy Ballou Nela Ponferrada KEY: Tier 3 - Direct impact Tier 4 - Indirect impact M Measure of Success () Page 21 of 65

22 report defects as soon as discovered. Unit/Area managers will conduct random gurney inspections on a monthly basis and each gurney will be assessed annually at a minimum for mattress integrity. Results of annual inspection will be documented on each area's gurney inventory worksheet. Sharon Kwong Jennie Farr The Critical Care Nurse Manager or designee will conduct daily rounds to ensure proper placement of drainage bags. Observation 5. The blinds in Outpatient Infusion Centre and on 5A were dirty. This could put medically compromised patients at risk. EP1, Obs 5; 4C & 5A BLINDS: On 1/13/2014 the blinds in 4C Infusion Center and 5A Solarium were removed and replaced with curtains and windows cleaned. Francisco Saenz Organization findings (pg 46 of 86): [CONTINUED] Observation 6. During a tour of the Psychiatric Emergency Service it was noted that at least two sleeping chairs had split seams which could create an infection control risk. EP1, Obs 6; PES CHAIRS: Effective 12/20/2014 the two sleeping chairs were temporarily covered until replacements are delivered. Effective 1/7/2014 all furniture in PES was inspected for integrity. Effective 1/10/2014 the P.O. for replacement furniture was submitted to Materials Management; delivery date is pending. Effective 1/13/2014 inspection of furniture for integrity has been added to the PES unit EOC checklist used by unit managers or designated staff when conducting unit EOC rounds. Obs. 6: Nurse Manager or designee will conduct weekly EOC rounds to assess for on-going compliance with individual bottles in shower room, washer/dryer cleanliness, and condition of PES sleeping chairs and other vinyl surfaces. Elaine Dekker Kathy Jung Leslie Dubbin Kathy Ballou Francisco Saenz Sarah Doernberg Kathy Ballou Nela Ponferrada Sharon Kwong Jennie Farr EP 2 On 4B, it was noted that a Social Worker was not wearing PPE properly. The gown was not tied at the neck, and the gown was falling from her shoulder. EP2; 4B SW & PPE: At the time of the finding, over-the-head isolation gowns are the approved PPE, not gowns that tied/fastened at the neck. The SW was observed with a gown that fastened at the neck via Velcro tabs, not strings. Effective 1/3/2014 the SW was instructed by the Infection Control Program Manager regarding the proper PPE gowns. Infection Control (IC) Policy 3.03 Contact Isolation was reviewed and revised to clarify that gowns must be secured Elaine Dekker Kathy Jung Leslie Dubbin Kathy Ballou Francisco Saenz Sarah Doernberg Kathy Ballou KEY: Tier 3 - Direct impact Tier 4 - Indirect impact M Measure of Success () Page 22 of 65

23 and tied properly at the neck and waist. Effective 1/14/2014, this revision was approved by the Infection Control Committee. Effective 1/14/2014, laminated direction signs were posted on isolation carts Nela Ponferrada Sharon Kwong Jennie Farr : EP2; 4B SW & PPE: The unit Infection Control Liaisons will conduct monthly random observation audits for four consecutive months to ensure staff use the approved PPE isolation gowns. Audit results will be reported monthly to Infection Control Committee, Nursing Administration Forum (NAF), and to Accreditation, Licensing Certification Committee (ALCC). Numerator: The number of approved PPE isolation gowns observed. Denominator: 25 observations of PPE use. EP 1 Noted in the dialysis area due to the physical constraints within the unit, the opportunity for crosscontamination between patients was very high. In addition, there was very limited contact isolation capabilities for a C- diff patient or any other type of transmission-based precautions. During staff interviews with the Infection Control coordinator, this issue was confirmed as to crosscontamination and lack of transmission-based precautions in the dialysis unit. CHRONIC DIALYSIS: The building where the Renal Service Outpatient Chronic Dialysis unit is located is close to one hundred years old. The Infection Control Program manager met with the Renal Service Outpatient Chronic Dialysis leadership staff to review infection control practices to prevent cross-contamination. Elaine Dekker Kathy Jung Max Bunuan Leslie Dubbin IC : EP 2, Tier 3, A, R (pg 48 of 86): The hospital implements infection prevention and control activities when doing the following: Performing intermediate and high-level disinfection and sterilization of medical equipment, devices, and supplies. * (See also EC , EP 4) Note: Sterilization is used for items such as implants and surgical instruments. High-level disinfection may also be used if sterilization is not possible, as is the case with flexible endoscopes. KEY: Tier 3 - Direct impact Tier 4 - Indirect impact M Measure of Success () Page 23 of 65

24 Footnote *: For further information regarding performing intermediate and high-level disinfection of medical equipment, devices, and supplies, refer to the website of the Centers for Disease Control and Prevention (CDC) at hilp:// erilizationfacknowledg.html (Sterilization and Disinfection in Healthcare Settings). EP 4, Tier 4, C, R, M (pg 49 of 86): The hospital implements infection prevention and control activities when doing the following: Storing medical equipment, devices, and supplies. Organization findings (pg 49 of 86): EP 2 It was found that the expiration for OPA strips was dated for 109 days after opening instead of 90 days as required by the manufacturer's instruction. Organization findings (pg 49 of 86): [CONTINUED] EP 4 During a tour of the Primary Care Clinic unwrapped disposable speculum were found in a drawer in the exam table. Staff member present was unaware that this presents an infection control risk. OPA STRIPS: Effective 1/3/14, SPD staff were educated to the following new procedure: Effective immediately, when a new bottle of Cidex OPA Test Strips are opened, a second SPD Tech is needed to verify the expiration date. The expiration must be 90 days after the bottle is opened. Both staff members must initial the bottle once completed. Memo to staff regarding same written 1/3/14. Effective 1/3/14, education commenced for all SPD Technicians via unit meetings and was completed by 1/6/14. Nurse Manager will complete spot checks for compliance. SPECULUMS: Following the ICM survey, the General Medicine Clinic, Family Health Center, Urgent Care Center leadership adopted an new policy for the hospital-based primary care clinics regarding single-use disposable speculums. All single use disposable speculums in the General Medicine Clinic, Family Health Center, Urgent Care Center are to be kept in their individual external packaging until the time of use. Speculums found outside of package or in torn or unsealed packaging will be discarded. Policy adopted, approved and implemented on 1/13/2014. Ditas Hernandez 100% Leslie Dubbin : SPECULUMS: The nurse manager or his/her designee will do weekly environment of care rounds for four consecutive months to assess for ongoing compliance. The nurse managers will do weekly audits of room preparation checklists to ensure documentation of compliance with the KEY: Tier 3 - Direct impact Tier 4 - Indirect impact M Measure of Success () Page 24 of 65

25 new policy. Numerator: all rooms in the clinic. Denominator all speculum drawers in the clinic. Audit results be reported to Infection Control Committee and to ALCC. EP 4 Noted in a C-Section room an Intraosseous Bone Kit was found. Within the kit was a damaged package which contained an Intraosseous needle. Sterilization integrity of the package had been compromised. BONE KIT: Effective 12/27/30, the Anesthesia Workroom Manager, Anesthesia Workroom Clinical Director, and Anesthesia OB Clinical Director completed a review of SFGH Infection Control Policy 6.08/Storage of Supplies (Clean/Sterile) "...All personnel are responsible to inspect visually any sterile package prior to use to check for time-limited shelf life label and conditions which would constitute a presumptive break in package integrity...". Effective 12/27/30, reviewed & updated Anesthesia Policy 'Monthly Expiration Checks' to include language of 'disposable inventory' Disposable inventory is already included in the monthly-performed expiration checks, but language in policy was not. Effective 12/27/13, the Anesthesia policy update was approved by Anesthesia Leadership. Effective 01/06/13, sent out universal to the Anesthesia Clinical staff (Faculty, CRNA's, Residents, Anesthesia Techs) reminding them to check integrity of packaging prior to any product use. : BONE KIT: The Anesthesia Techs will conduct random observations of the intraosseous bone kits for four consecutive months to ensure package integrity. 100% Leslie Dubbin Jim Marks Elaine Dekker Kyra Quon Sarah Doernberg Numerator: all intraosseous bone kits with intact packaging. Denominator: all intraosseous bone kits. Audit results will be reported monthly to Infection Control KEY: Tier 3 - Direct impact Tier 4 - Indirect impact M Measure of Success () Page 25 of 65