HospitalInspections.org

Based on document review and interview, the hospital failed to ensure that the infection control officer had been designated in writing as the appointed infection control officer. This deficient practice does not ensure that the infection control officer has the responsibility for the infection prevention and the control of the program, which can lead to the failure to monitor hospital-wide infections. The findings are:

A. Review of the infection control program did not indicate that the infection control officer had been designated in writing or approved by the hospital board as the appointed infection control officer.

B. On 06/13/12 at 8:30 am, during interview, the Chief Quality Officer stated that she was not aware that the infection control officer needed to be designated in writing and approved by the hospital board.

Based on observation, interview and document review, the hospital failed to develop an infection control risk assessment on a construction project underway in the hospital during the time of the survey. This deficient practice has the potential to affect issues relative to infection control, dust and debris, odors, noise, and outages which may develop during a construction project. The findings are:

A. On 06/13/12 at 9:30 am, during a tour with the Infection Control Officer, the surveyor observed that the hospital's second floor nursing station was under construction. The Infection Control Officer was asked if there was an infection control risk assessment developed for this construction project. She replied, "No."

B. Review of the hospital's policy titled "Guidelines for Infection Control During Construction and Renovation," last revised on 11/17/11, revealed the following: "The Directors of Engineering Services, Infection Control, and Safety are responsible for evaluating the need for infection control measures for every construction, renovation, modernization, or repair activity requiring the demolition, construction, or penetrating of any wall, ceiling, or floor slab. An Infection Control Assessment Screen (ICAS) must be completed prior to initiation of work. The log of all ICAS will be maintained by the Infection Control Practitioner..."

Based on observation, interview, and review of documentation the facility failed to implement the facility's infection control program to prevent and control infections by 1) not changing gloves after drawing blood from a patient and failed to change gloves after picking up trash; 2) not cleaning all equipment within the surgical suite during the terminal cleaning, and 3) not using cleaners and disinfectants in accordance with manufacturer's instructions. These deficient practices had the likelihood to spread infectious diseases throughout the hospital to patients, visitors and staff. The findings are:

A. On 06/12/12 at 11:00 am, Laboratory Technician (LT) #1 was observed in the newborn nursery drawing a blood sample. The following was observed with the Chief Quality Officer (CQO):
1. After LT #1 completed the collection of blood, she failed to change her dirty gloves before touching the side glass of the baby bassinet to put the glass back in place. With the same dirty gloves LT #1 picked up a pen on the computer, laid the blood tubes on the desk to label them, and then returned the pen to the computer. LT #1 did not wipe anything down and did not remove her gloves until she was ready to leave the area.
2. An interview during this observation was conducted with the CQO. When asked if the dirty gloves should have been worn after the blood collection, the CQO stated that they should have been removed and clean ones put on.
3. The facility's policy titled "Hand Hygiene" effective 12/2011, revealed "3. Gloves should be changed when caring for a single patient when moving from one procedure to another."

B. On 06/12/12 at 12:22 pm, Housekeeper #2 was observed walking in the hallway of the pre-surgical suite picking up trash with gloves on. Without changing gloves he touched a door handle that led to a janitors closet, went inside, came out and then started cleaning an office area adjacent to the pre-surgical suite.
1. On 06/12/12 at 12:24 pm, the CQO stated that gloves should be changed from one activity to another.
2. On 06/12/12 at 12:25 pm, during interview, Housekeeper #2 stated that he did not change his gloves but that he would change his gloves next time.
3. The facility's policy titled "Hand Hygiene," effective 12/2011, revealed "2. Gloves should be changed, and hand hygiene performed after using gloves for contaminated activities."

C. On 06/12/12 at 3:22 pm, observation of the terminal cleaning of operating room (OR) #6 was conducted with the CQO, the OR Director and Housekeeper #3. The following was observed:
1. The housekeeper did not clean the ventilator machine because he was told by the OR Director not to clean it. The ventilator machine remained in the room without being cleaned.
2. On 06/14/12 at 10:27 am, an interview was conducted with the CQO. When asked if the ventilator machine should have been cleaned during the terminal cleaning of OR #6, she stated that it should have been cleaned.
3. The facility's policy titled "Infection Control in Housekeeping," effective 12/2011, revealed "5. At the conclusion of the operating schedule, the operating rooms, scrub and utility areas, corridors, furnishings, and equipment are to be terminally cleaned."

D. On 06/13/12 at 9:45 am, a tour of the medical/surgical floor was conducted with the Infection Control Officer. The housekeepers were observed cleaning patient rooms and spraying a solution on counter surfaces and sinks in a patient room.
1. Housekeeper #1 was asked how long is the cleaning solution was to stay on the surface wet until the surface is wiped with a cloth. She replied that she did not know how long. Housekeeper #1 pointed to the bottle of disinfectant that she removed the solution from. Review of the bottle of disinfectant called "Vindicator + One Step Disinfectant" revealed the following: "...Allow to remain wet for 10 minutes, then remove excess liquid..." After reading this, Housekeeper #1 stated that the solution does not remain on the surface for 10 minutes. "Maybe 2 minutes but not 10 minutes."
2. On 06/13/12 at 11:00 am, during interview, the Housekeeping Supervisors were shown the directions for use on the disinfectant bottle being used by Housekeeper #1. The Housekeeping Supervisors were then asked how the staff were educated on how long surfaces were to remain wet with the disinfectant "Vindicator + One Step Disinfectant" before the housekeepers remove the excess liquid. They replied that the housekeepers watch a video on how to clean a patient room using a generic disinfectant and then sign a document that indicates that they reviewed the video. The Housekeeping Supervisors were then asked if the housekeeping staff were inserviced using the current disinfectant. They replied that the housekeeping staff would be inserviced on using the current disinfectant.