'Infection control' issues temporarily shut down a hospital's operating room last summer
WEST JORDAN (KUTV) — The operating room of a Utah hospital was temporarily shut down after an inspection found “serious” issues with sterilization.
That shut down happened last July. It's coming to light now thanks to the digging of a West Jordan woman whose mother died at the hospital.
Lori Van Roosendaal-Thompson's 79-year-old mother went in for a gallbladder removal at the Jordan Valley Medical Center. She says her mom developed an infection and subsequently died.
Several months later, Van Roosendaal-Thompson says a friend who used to work at the medical center gave her a tip: around the time her mother was in the hospital, the facility was being investigated by the state health department.
Van Roosendaal-Thompson requested a copy of what health officials found and received a 55-page report.
It reads:
The hospital failed to provide a sanitary environment to avoid sources and transmission of infections and communicable diseases.
The report lists several examples including that the hospital "failed to ensure...that their infection control program was functioning," "there had been an issue with [instrument] washers," and "staff was noticing a ‘film’ and brownish colored staining on surgical instruments."
The hospital was reportedly past due on its bills to companies that provide chemicals to the hospital that are used to clean drains in the operating rooms.
"We are in critical need," a June email to administrators said. "Waste (blood infected)," was, "backing up into the drains and onto the floors."
Twice, the report mentions that “bio-burden” from other patients was found still adhered to surgical instruments after the instruments had gone through sterilization. Bio-burden is human tissue.
In the case of someone identified as Patient 6, "the instrument was not used but was part of a set that was used," the report reads. "The set itself was contaminatedso yes the patient was exposed."
In the case of someone identified as Patient 12, a "dirty" instrument "had the potential to expose Patient 12 to infectious disease," the report reads. Patient 12 "developed an infection within two days of surgery."
On July 31, the Utah Health Department classified the situation as "immediate jeopardy" and the operating room was shut down.
“'Immediate Jeopardy' means there's some immediate risk,” says Joel Hoffman with Utah’s Bureau of Health Facility Licensing. That’s the division within the state health department that responds and investigates complaints against hospitals.
"Infection control is always serious,” he said adding that in 28 years, it's "one of the most serious things that [he's] seen in infection control with any hospital."
Hoffman says the hospital was immediately responsive, addressing all issues and the operating room was back up and running by the next day.
"They came up with policies, procedures and changes to get that equipment taken care of the appropriate way,” Hoffman said.
Beyond the findings in the report, there is something else that Van Roosendaal-Thompson says troubles her: had she not stumbled upon the report, she never would have known any of it.
“I feel like they should be contacting people,” she said.
The report shows hospital staff knew about the potential infection control issues, but patients were not notified.
“I don't know if that's okay or not,” Hoffman said. “We do what we are asked to do as a public health department. At this point, we don't have a way to get that out there. We certainly could but at this point, we have not."
Jordan Valley Medical Center is a Steward Health Care facility. Steward’s vice president of communications responded to questions from KUTV in an email attributed to Jordan Valley Medical Center.
It reads, “Patient care is of the utmost importance to Jordan Valley Medical Center. The hospital cooperated fully with a recent survey completed by representatives of the Utah State Bureau of Health Facility Licensing. Any issues were immediately addressed and resolved and at no time were there any impacts on patient outcomes.
“We thank the Bureau of Health Facility Licensing for the important work they do to maintain the highest standards across all Utah hospitals. We remain committed to providing the highest quality healthcare services to our community.”
Steward declined to answer questions related to Van Roosendaal-Thompson’s mom citing privacy laws.
The hospital also responded to state health officials spelling out the hospital’s plan of correction.
"Jordan Valley Medical Center has implemented an infection prevention program plan," hospital administrators wrote.
Part of the plan involves training for transporting instruments and opening sterile packs. Staff were also trained on how to properly maintain the sterilizers and what to do if they fail, administrators wrote.
KUTV found no evidence connecting Van Roosendaal-Thompson’s mom's death with the sanitary conditions in the operating room. The inspection was conducted July 31, 2019, through August 6, 2019. Her mom underwent surgery on June 14, 2019, and died on June 25, 2019.
Hoffman says the Utah Health Department is "not aware of any patients who were affected by this" and that there "have been no further issues."
