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West Virginia Licensure Rule CSR 64-12-5

5.1.b.1 The following documents are adopted as construction, equipment, physical facility, and related procedural standards for all existing hospitals, all new construction and any additions, alterations, renovations, or conversions of existing buildings: The relevant sections of the 2001 edition of The Guidelines for Design and Construction of Hospitals and Health Care Facilities as recognized by the American Institute of Architects Academy of Architecture for Health with assistance from the United States Department of Health and Human Resources shall be used as planning standards;

5.1.b.2 The following documents are adopted as construction, equipment, physical facility, and related procedural standards for all existing hospitals, all new construction and any additions, alterations, renovations, or conversions of existing buildings: The National Fire Protection Association codes and standards relevant to Health Care Facilities including the National Electric Code and the 2002 Edition of N.F.P.A. 99 Standard for Health Care Facilities;

5.4.a Additions and renovations or alterations of any hospital which are begun after the effective date of this rule shall comply with the General and Psychiatric Hospital sections, as applicable, of the latest edition of Guidelines for Design and Construction of Hospitals and Health Care Facilities.

5.4.d The hospital shall submit to the Director for review, complete construction drawings and specifications for any hospital construction project which alters a floor plan, impacts life safety or requires approval under W. Va. Code §16-2D-1 et seq. prior to beginning work on the project. An architect and/or engineer registered to practice in West Virginia, shall prepare and sign the drawings and specifications including architectural, life safety, structural, mechanical and electrical drawings and specifications. Minor renovations which alter floor plans may not require the services of an architect and a full set of drawings. However, an actual as built drawing is required for the specific area to be renovated. The approval of minor renovations shall be determined by the Secretary.

This Standard is not Met as evidenced by:

Based on observation and staff interview it was determined the hospital failed to meet all standards for licensing established by The Office of Health Facility Licensure and Certification for the state of West Virginia and in accordance with (West Virginia Licensure Rule CSR 64-12-5, 5.1.b.1, 5.1.b.2, 5.4.a, and 5.4.d ) for renovations and additions to the hospital. This failure has the potential to adversely affect the care of all patients treated in the renovated rooms.

Findings include:

1) During tour of the 2nd floor of the hospital on 02/23/10 at approximately 10:00 a.m., the following renovation and alteration of the hospital's original building construction was observed:

a) Hospital patient rooms 214 and 215 were converted into an endoscopy procedure room and a clean/dirty scope reprocessing room. An interview with the Plant Operations Director on this same date and time confirmed that the renovation of these rooms took place approximately seventeen (17) months ago. Also, this interview revealed there was no documentation available to indicate these construction renovation plans were submitted to the Office of Health Facility Licensure and Certification for approval. Therefore, the renovation of these two (2) rooms for endoscopy services has not been approved by the authority having jurisdiction (Office of Health Facility Licensure and Certification).

Based on observation, staff interview, and documentation review during the survey conducted 02/22/10 to 02/25/10, it was determined due to the volume of deficiencies issued to the hospital for non-compliance with the 2000 Edition of the Life Safety Code, that the hospital failed to maintain the environment and all equipment to ensure the safety of the patients, staff, and public. Therefore this Condition is not met. Refer to Life Safety Code deficiencies identified as tag numbers K029, K052, K054, K062, K064, K069, K144, and K147. Also, citation identified as C221.

Based on observation and staff interview it was determined the hospital failed to maintain a sanitary environment for all patients treated in the operating rooms. This failure has the potential to adversely affect the care of patients treated in the operating rooms.

Findings include:

1) On 02/23/10 at approximately 2:30 p.m., a wall in the sub-sterile room of the OR (operating room) was observed to be damaged and a piece of plastic material was partially covering the damaged area. Also, at this same time a patient was observed in OR #1. The surgeons must pass thru the sub-sterile room to get to the operating rooms. Also, a flash sterilizer is located in the sub-sterile room. An interview with the Plant Operations Director on this same date and time revealed that the construction on the wall started on 02/22/10 and that no patients were scheduled for the operating rooms on that day. This interview also revealed that since the project was not completed, a piece of plastic was used to cover the area. Since a sterile environment cannot be maintained with the ongoing construction project, it was communicated to administration and plant operations that the operating rooms must not be used for patient services until the construction project is completed.

2) An interview with the Plant Operations Director on 02/24/10 revealed that the OR area was not in use for patient services on 02/24/10 and the construction project (wall repair in sub-sterile room) was completed on that date. On 02/25/10 at approximately 11:00 a.m. the wall in the sub-sterile room was observed to be repaired and sealed.

Based on observation, documentation and staff interview it was determined the Organizational Structure was such that the governing body failed to monitor the Critical Access Hospital's total operation and ensure the policies are administered with quality in a safe environment. The deficient practice included the volume of environmental and life safety deficiencies cited for non compliance using the 2000 Edition of the Life Safety Code and the deficiencies cited related to the physical plant. In addition, it was determined the hospital failed to furnish and maintain surgical services with an acceptable cleaning process for a colonoscope and bronchoscope; these processes potentially affect the quality of care provided to all patients who received bronchoscope and colonoscope procedures. It was determined the hospital failed to provide an environment that would ensure the safety of all patients under-going any of the above procedures. Therefore, the governing body failed to ensure that quality healthcare was provided in a safe environment.

Refer to the following tags: C152 (State and Local Laws and Regulations - Prior to renovation of the Endoscopy Suite, the hospital failed to obtain approval of their construction plans from the authority having jurisdiction); C221 (Construction Standards - The hospital failed to maintain a sterile environment in the operating room); C257 (Responsibilities of the MD or DO - The physician failed to sign history and physicals and discharge summaries); C260 (Responsibilities of MD or DO - Physician failed to review and sign the history and physical and orders written and progress note written or given by the Nurse Practitioner); C278 (Patient Care Policies - The hospital failed to ensure the Infection Control Program adequately investigated potential infectious processes and identify potential Infection Control issues and failed to be involved in the construction of patient care areas); C320 (Surgical Services - The hospital failed to maintain safe and adequate cleaning procedures for surgical scopes).

Life Safety Tags include: K29 (Hazardous Areas - The hospital failed to maintain a soiled linen holding room door that would close properly); K52 (Fire Alarms - The hospital failed to maintain five (5) heat detectors that were not operable); K54 (Smoke Detectors - The hospital failed to complete a smoke detector sensitivity test); K62 (Sprinkler System - The hospital failed to maintain all the components of the sprinkler system); K64 (Portable Fire Extinguishers - The hospital failed to maintain a current hydro-test); K69 (Kitchen Range Hood Extinguishing System - The hospital failed to have the system tested every six (6) months); K144 (Hospital Generator - The hospital failed to maintain emergency lighting in the transfer switch room); and K147 (Operating Room Electrical Wiring - The hospital failed to maintain certification for the line isolation monitor).

The identified deficient practices have the potential to negatively affect the safety and quality of care provided to patients.

Based on document review, medical record review and staff interview the hospital failed to ensure the physician follows the Medical Staff Rules & Regulations by authenticating orders, signing History and Physicals (H&P) and Discharge Summaries (D/C) and completing medical records in five (5) of five (5) closed inpatient medical records (patients #6, 14, 16, 18 and 19), one (1) of one (1) closed observation medical records (patient #17) and one (1) of three (3) open medical records (patient #20) reviewed. This has the potential to negatively impact all patient care by leaving the patient with inaccurate orders and incomplete information for continuity of care.

Findings include:

1) Plateau Medical Center Medical Staff Rules and Regulations, last revised 3/2009, state in part "...2.2 Each patient admitted for inpatient care shall have a completed admission history and physical examination...within twenty-four (24) hours of admission...2.8 All clinical entries in the patient's medical record, including written and verbal orders, shall be accurately dated, timed and authenticated...2.15 The written or dictated discharge summary shall be completed within thirty (30) days of discharge...2.16 Patient medical records are required to be completed within thirty (30) days of discharge...3.2 The physician who gave the verbal order or another practitioner who is also responsible for the care of the patient shall authenticate and date any order, including but not limited to medication orders, as soon as possible, such as during the next patient visit, and in no case longer than forty-eight (48) hours from dictating the verbal order..."

2) Review of the medical record for patient #6 revealed the Consultation Report was dictated on 12/21/09 at 2020 with the physician's signature dated 2/15/10 at 0900. The Operation Report was dictated 12/22/09 at 0901 with the physicians signature dated 2/15/10 at 0900. Also on the Operation Report, the procedure performed is not documented.

3) Review of the medical record for patient #14 revealed the H&P was dictated on 11/26/09 at 0848, the patient was discharged 11/28/09, the D/C Summary was dictated 11/28/09 at 0742. The H&P was electronically signed by the physician on 2/2/10 at 1724 and the D/C Summary was electronically signed by the physician on 2/2/10 at 1400.

4) Review of the medical record for patient #16 revealed the patient was admitted 11/24/09 and discharged 12/3/09. There is no documented evidence of a D/C Summary. The patient was originally admitted as an observation patient and then made a full-admit on 11/25/09. The full-admit orders were written by the nurse on 11/25/09 and not authenticated by the physician until 1/27/10. Telephone orders were written on 11/24/09 at 2035, 11/28/09 at 1100, 11/29/09 at 1935 and 12/1/09 at 1410 all with no authentication by the physician. A verbal order was given for Insulin sliding scale coverage on 11/25/09 and not authenticated by the physician until 1/27/10.

5) Review of the medical record for patient #17 revealed the patient was admitted as an observation patient on 1/4/10 and discharged on 1/5/10. The H&P was not dictated until 2/18/10 at 1307 with no documented evidence of the physician's signature. The D/C Summary was not dictated until 2/18/09 at 1339 with no documented evidence of the physician's signature.

6) Review of the medical record for patient #18 revealed the patient was admitted as an observation patient on 1/4/10 and discharged on 1/7/10. There is no documented evidence of a D/C Summary. The Operation Report was dictated 1/5/10 at 2143 with no documented evidence of a physician's signature.

7) Review of the medical record for patient #19 revealed the Operation Report was dictated on 12/15/09 at 1645 with no documented evidence of a physician's signature.

8) During an interview with the Medical-Surgical Nurse Manager (MSNM) in the afternoon of 2/25/10, the closed medical records were reviewed and the MSNM agreed with the above findings.

9) Review of the medical record for patient #20 revealed telephone orders on 2/23/10 at 1110, 1115, 1312, 1715 and 1900 with no documented evidence of a physician's authentication. There is, however, documented evidence, by progress notes and orders, in the medical record of physician visit to the patient on 2/24/10. During an interview at 1200 on 2/25/10, the Intensive Care Unit Manager reviewed the medical record and agreed with these findings.

Based on document review, medical record review and staff interview the hospital failed to ensure the physician reviews and signs the History and Physical dictated by, orders written or given by and progress notes written by the Nurse Practitioner (NP) in three (3) of four (4) closed surgical inpatient medical records (patients #8, 18 and 19) reviewed. This has the potential to negatively impact all patient care by not ensuring the patients receive appropriate and adequate medical care.

Findings include:

1) Plateau Medical Center Medical Staff Rules & Regulations, last revised 3/2009, states in part, "...1.1(e) The management and coordination of each patient's care, treatment and services shall be the responsibility of a physician with appropriate privileges...2.1 The Attending Physician shall be responsible for the preparation of a complete and legible medical record for each patient. Its contents shall be pertinent and current...2.2 If the history and physical is completed by a licensed independent practitioner who is not a physician or oral and maxillofacial surgeon...must be endorsed by a qualified physician..."

2) Review of the medical record for patient #8 revealed the following: The History & Physical was dictated on 12/4/09 by the NP, reviewed on 12/13/09 by the NP with no documented evidence of the physician's signature. The D/C summary was dictated on 1/7/10 at 1059 by the NP, signed on 1/12/10 by the NP with no documented evidence of the physician's signature. A 12/12/09 telephone order was given and authenticated by the NP with no documented evidence of a physician's signature.

3) Review of the medical record for patient #18 revealed the following: A verbal order was given by the NP on 12/31/09 with no physician signature; telephone orders were given and authenticated by the NP on 1/4/10 at 1945, 1/6/10 at 0155 and 0200 all with no physician signature; and orders were written by the NP on 1/5/10 at 0930, 1/6/10 at 0720, 1600 and 1/7/10 at 0830 all with no physician signature. Also, progress notes were written by the NP on 1/5/10 at 0930 and 1/6/10 at 1600 with no physician signature on either day.

4) Review of the medical record for patient #19 revealed the following: The Discharge Summary was dictated on 1/7/10 at 1056, signed by the NP; however, there is no physician signature. A telephone order was given and authenticated by the NP on 12/16/09 at 0900 with no physician signature; orders were written by the NP on 12/15/09 at 0915, 1145, 12/16/09 at 0900, 1055, 1700 and discharge medication orders - all with no physician signature. Also, progress notes were written by the NP on 12/15/09 at 1030 and 12/16/09 (no documented time) with no physician signature on either day.

5) During an interview with the Medical-Surgical Nurse Manager (MSNM) in the afternoon of 2/25/10, the medical records were reviewed and the MSNM agreed with the above findings.

Based on observations, reviews of documents and interview with staff, it was determined the facility failed to ensure the Infection Control program adequately investigated potential infectious processes, failed to adequately identify potential Infection Control issues in the hospital and failed to be involved in construction in patient care areas. These have the potential to affect the accuracy of the Infection Control program in determining the rates for Healthcare Associated Infections (HAI) and Surgical Site Infections (SSI). These deficient practices also have the potential to unnecessarily expose patients to pathogens during procedures or routine patient care.

Findings include:

1) The Infection Control program for the 2009 year was reviewed. The Infection Control Nurse was interviewed in the morning on 2/25/10. The Infection Control Nurse provided information which indicated that between January and December 2009, the hospital had provided 1151 surgical procedures and 644 endoscopy procedures. Review of inpatient logs for the month of December revealed the hospital routinely provides inpatient services which include the provision of urinary catheters, intravenous therapy, endotracheal tubes and ventilators for patient care. The hospital also has some patients which have had a length of stay longer than one (1) week. All these factors increase the risk of hospital acquired infectious processes for patients.

Review of the information provided by the Infection Control Nurse for the 2009 year revealed the "Infection Control Log" is a book of copies of lists of patients who had a positive culture for each month. The Infection Control Nurse stated the laboratory provides the lists to her and she places the lists in the log book. As an example of the lists, for the month of November 2009, there were sixty (60) positive cultures. For the month of December 2009, there were forty-eight (48) positive cultures. The Infection Control Nurse was questioned about what the Infection Control Program does with the information from the laboratory. She stated she reviews every chart to determine if there are any trends, SSIs, HAIs or outbreaks. She stated she has made no notation anywhere of each record review. The Infection Control Program cannot show that any investigation has been made into any positive culture reported from the laboratory to the Infection Control Nurse.

The Infection Control Nurse stated that the Infection Control Program has not ascertained any SSI or HAI, any outbreaks or any trends during the entire 2009 year.

2) During a tour of the Operating Room (OR) area on 2/23/10 at 2:30 p.m., it was noted there is a sub-sterile room between OR rooms #1 and #2. During the time of the tour, an exploratory laparotomy case was in progress. The sub-sterile room had a flash sterilizer. The Interim Nurse Manager of the OR stated the flash sterilizer had been used at least one (1) time that day during a surgical procedure. It was noted there was a large area on the wall inside the sub-sterile room, at least four (4) feet by four (4) feet, that was covered with clear plastic which was taped to the wall. Through the plastic, it could be seen the dry wall had been ripped and shredded. The Interim Nurse Manager stated the maintenance department was in the process of taking down a cabinet and replacing the wall board. She stated the plastic was covering the wall until the construction could be completed.

During interview with the Infection Control Nurse, she stated she expects to be notified by the maintenance department prior to any renovations or constructions so she can do a risk analysis. She stated she had not been aware the construction in the sub-sterile room was taking place. The construction process was not conducive to the provision of surgical services as the area could not be adequately cleaned, nor could the dust under the plastic be adequately controlled.

3) During the same tour of the OR, it was noted that no staff were wearing masks into the sub-sterile area during the time the surgical procedure was taking place. As noted in finding #2, the Interim Nurse Manager stated the flash sterilizer present in the sub-sterile area had been used that day. She also stated that all persons enter each OR room through the sub-sterile area after they have scrubbed. Review of policy "Surgical Attire", effective 4/05 states "All personnel entering the restricted area of the operating room suite should wear high filtration masks, including in the room in which the patient's surgical procedure is performed, the cores, and other designated areas, where open sterile supplies or scrubbed persons may be located." Policy "Traffic Control" (for the OR), effective 4/05 states "Restricted area - traffic is limited to personnel who must wear scrub attire, cap, and mask. This area includes the induction/operating rooms, sub-sterile areas where unwrapped supplies are sterilized, the scrub room and the clean center core."

During interview with the Infection Control Nurse, she stated she visits the OR and the endoscopy procedure room and decontamination room weekly to observe infection control procedures. She stated she had not been aware the staff were not wearing masks in the sub-sterile area in accordance with hospital policy and accepted standards of care.

Based on observations, review of documents and interview with staff, it was determined the facility failed to ensure endoscopic procedures are provided in accordance with hospital policy, accepted standards of care and manufacturer recommendations. This deficient practice may have affected the quality of care provided to three (3) of three (3)patients reviewed who received endoscopic procedures on the day of the observations (patients #10, 11 and 12). There is a potential for the hospital to provide endoscopic procedures in an unsafe manner by potentially exposing patients to equipment that is contaminated with pathogenic microorganisms. It was determined the deficient practice constituted an Immediate Jeopardy situation for all patients who undergo an endoscopic procedure. The Immediate Jeopardy situation was removed as of 4 p.m. on 2/24/10 by the Facility Administrator providing a written statement attesting that no endoscopic procedure would be performed until after the deficient practices are corrected and verified by a State surveyor re-visit. The facility was unable to change the construction of the decontamination room and was unable to adequately re-train all individuals on proper cleaning and disinfecting techniques of the endoscopes prior to the end of the survey, therefore the facility had continued Condition of Participation level non-compliance at the time of the end of the survey on 2/25/10.

Findings include:

1) Review of the endoscopic procedure list and medical records revealed that patients #10, 11 and 12 received endoscope procedures in the morning on 2/23/10. All three (3) patients had an EGD (esophagastroduodenoscopy) with the same scope, #EGD2970K.

The scheduled procedures were completed and the endoscopy procedure room was not in use at the time of the observations. The endoscopy procedure room and the endoscopy decontamination room were observed at 11:00 a.m. and again at 1:30 p.m. on 2/23/10. The Surgical Services Interim Nurse Manager, the Central Sterile (CS) Services Supervisor and two (2) CS technicians were present during the observations. The policies relative to cleaning and disinfecting the endoscopes were reviewed in the afternoon on 2/23/10. Manufacturer's instructions relative to the cleaning and disinfecting solutions were reviewed at the time of the observations conducted at 11:00 a.m. and confirmed with the staff present at that time.

It was determined the facility had the following deficient practices (as noted in findings 2-8) relative to procedures for cleaning, disinfecting and storing endoscopes in order to ensure a properly disinfected scope was used for each patient in accordance with policy, accepted standards of care and manufacturer recommendations. As noted in the following findings, the decontamination room has been in use for more than one (1) year, although it was not possible to identify the beginning dates of each component of the deficient practices. The information was conveyed to the CMS Regional Office in the morning on 2/24/10. At the direction of the Regional Office, the hospital administrator was verbally notified at 9:40 a.m. on 2/24/10 that Immediate Jeopardy existed. No endoscope procedures were scheduled or performed on 2/24/10.

2) It was observed the endoscopy decontamination room was constructed and maintained in such a way as to create the potential for cross contamination between the dirty and the disinfected (clean) endoscopes. The washing (decontamination), disinfection and storage of the scopes are being carried out in the same room without any separations or barriers.

It was observed that the endoscopy procedure room has a small "pass-through" window into the endoscopy decontamination room. The dirty endoscopes are passed through the window from the procedure room to the decontamination room after patient use to the CS technician for cleaning and disinfecting. It was observed the decontamination room had only one (1) double sink in the room. The room also contained cabinets for storage of endoscopes. At the time of the afternoon observation, the CS Supervisor stated the cabinets are used for storage of endoscopes which have been disinfected and are ready for patient use.

In the afternoon on 2/23/10, the Maintenance Supervisor stated two (2) patient rooms had been converted into the endoscopy procedure room and the endoscopy decontamination room sometime in 2008.

3) Review of the 2/23/10 procedure list and medical record reviews revealed that patients #10, 11 and 12 received endoscope procedures in the morning of 2/23/10 prior to observations of the endoscopy area. All three (3) patients had an EGD (esophagastroduodenoscopy) with the same scope, #EGD2970K. The staff failed to clean and disinfect the scope in between procedures in accordance with accepted standards, hospital policy and manufacturer recommendations, creating the potential for using an inadequately disinfected endoscope.

Review of hospital policy "Cleaning, Disinfection, Sterilization of Endoscopes and Accessories", last reviewed 8/09, reveals the policy states "If soaking in Cidex OPA: ...Meticulously clean all endoscopes and accessories and dry completely prior to immersing in Cidex OPA to prevent dilution of the OPA solution...allow scope to remain in disinfectant solution for recommended time (12 minutes at 20 degrees C/68 degrees F);" The policy states the scope is removed from the disinfection solution and rinsed again in water prior to storage or use.

Review of the manufacturer's instructions for the Cidex OPA being used for "manual reprocessing" revealed the manufacturer states the solution will produce "High level disinfectant at a minimum of 20 degrees C (68 degrees F). Cidex OPA Solution is a high level disinfectant when used or reused, according to the Directions for Use, at or above its Minimum Effective Concentration (MEC) as determined by Cidex OPA Solution Test Strips, with an immersion time of at least 12 minutes for a reuse period not to exceed 14 days." The information sheet states "The solution in the secondary container can be used for a period up to 14 days. The product must be discarded after 14 days. The product must be discarded after 14 days even if the Cidex OPA Solution Test Strip indicates a concentration above the MEC." The information sheet stated the solution must be used for a "minimum of 12 minutes at 20 degrees C or 68 degrees F or higher to destroy all pathogenic microorganisms."

The tub of Cidex OPA used to disinfect the scopes was observed after the three (3)procedures for patients #10, 11 and 12. There was no label on the container to indicate when the solution was placed into the container, nor when the solution would expire. Upon questioning, one of the CS technicians stated the information was being written on a calendar. Review of the calendar for January and February 2010 revealed that on 1/15/10, it was noted "time to change Cidex". On 1/19/10 it was noted "changed cidex". On 2/2/10, it was noted "time to change Cidex". On 2/22/10 it was noted "time to change Cidex." The CS technician stated that he was planning on changing the solution "later today" on 2/23/10. When questioned about how many days the solution had been in use, he stated he did not count the weekend days or days the solution was not used as part of the fourteen (14) days. The staff could not verify the exact date the solution had been changed prior to the disinfection of the scopes on the morning of 2/23/10, other than the 1/19/10 change documented on the calendar.

Review of the "Daily Cidex OPA Temperature Monitor" for the month of February 2010 revealed that on 2/23/10, the temperature of the Cidex OPA was recorded to be 65 degrees F, below the manufacturer recommendation of at least 68 degrees. The CS technician who was present during the 2/23/10 procedures stated that she checked and logged the temperature prior to any of the procedures being done that day. Further review of the log revealed it was pre-printed that the "acceptable range" was "59-86 degrees F". The staff who were present at the time of the observations could not explain why the sheet was printed with an incorrect acceptable range.

4) The CS technician who was present during the 2/23/10 procedures stated she decontaminated the scope (in between each procedure) in one side of a double sink. She stated she rinsed the scope in the second sink of the double sink and immersed the scope in a solution of Cidex OPA for 12 minutes for "high level disinfection". After disinfection, the scope was rinsed again in the same "rinsing side" of the sink. The practice of rinsing the scope in the same sink before and after the high level disinfection created a potential to re-contaminate the scope prior to use on a patient.

5) The CS technician who was present during the 2/23/10 procedures stated she decontaminated the scope (in between each procedure) in one side of a double sink by wiping the outside of the scope with undiluted Enzol product and squirting the undiluted Enzol through the scope.

The Enzol solution manufacturer instructions stated the solution should be diluted one (1) to two (2) squirts into one (1) gallon of water and the scopes should be immersed and soaked for a minimum of one (1) minute. The instructions stated the solution should be diluted to prevent damage to the scopes. Currently the staff is not immersing the scopes into a soaking solution, and the solution is not being diluted as recommended to prevent possible damage of the scopes.

6) Review of hospital policy "Cleaning, Disinfection, Sterilization of Endoscopes and Accessories", last reviewed 8/09, reveals the policy states that after soaking in Cidex OPA, the procedure is to "Remove the scope from (Cidex OPA) solution and place in 2 gallons of sterile water. Rinse three times in different containers of sterile water for at least one minute in duration per rinse; flush all channels with water with 90 cc; and suction 90 cc of alcohol, followed by forced air drying or 90 cc of air, before scope is stored."

The CS technician who was present during the 2/23/10 procedures stated that after disinfection the scope was rinsed in the "rinsing side" of the sink. The CS technician stated she dried the inside of the scope by pushing air through with a syringe. She stated the rinsing procedures did not include immersion in three (3) water baths as the policy states, nor any flushing with alcohol.

7) Observations of the storage cabinet at 1:30 p.m. revealed the cabinet did not appear to be clean. There was a dirty towel in the bottom of the cabinet, dust in the top, and drip spots and stains. When the Supervisor of the CS was interviewed, she stated she was not aware of any specified cleaning schedule for the cabinet. She concurred that the scopes are supposed to be cleaned and ready for patient use when hanging in the cabinet.

8) The Infection Control Nurse was interviewed in the morning on 2/25/10. She stated that as part of routine surveillance, she visited the Operating Room suite and the endoscopy procedure room and endoscopy decontamination room weekly. She stated she reviews logs, observes techniques and checks for staff compliance with accepted standards of care relative to infection control. She stated she had not observed any problems with technique with the endoscopy processing. She also provided information relative to the number of endoscopy procedures performed, and she stated there had been over 600 procedures performed during the 2009 year.