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Based on observation, review of sterilization documentation for 08/2017 and 09/2017, policies, and interview, the Facility failed to prevent likely sources of infection in that their policy for sterile processing of out of hospital equipment was not followed for two of two (09/28/17 and 08/15/17) Immediate Use Steam Sterilization (IUSS) events. The failed practice did not ensure Patients would be protected from the likely sources of infection. The failed practice likely affected the two patients listed on the IUSS record. Findings included:

A. Record review on 09/28/17 of the Facility's policy titled, "Sterile Processing: Out of Hospital Equipment" dated 11/2015 showed that:
1. All equipment/devices brought into the Facility from outside sources shall be delivered to Sterile Processing/Central Sterile by vendors/detail persons where they will be wiped clean with a disinfectant if in a plastic covered sterile container or washed and sterilized for use if wrapped by another Facility.
2. Vendor/detail individual will deliver equipment/devices for surgical use to Sterile Processing/Central Sterile at least 12-24 hours prior to use in Surgery, to provide adequate lead time to prepared surgical supplies.

B. The Director of Peri-operative Services was interviewed on 09/28/17 at 10:15 AM and stated that all surgical instruments brought into the Facility by vendors are taken to the Sterile Processing Department and sterilized in Surgical Services prior to use.

C. Observation on 09/28/17 at 10:39 AM of the Main Operating Room (OR) suite showed an Immediate Use Steam Sterilization (IUSS) Record for Autoclave #4 dated 09/28/17. Review of the IUSS cause showed Instruments brought in by a Sales Representative (Rep) with the comments "Rep says just received last night." Documentation showed the instruments were sterilized after being brought to the inner core and processed using an IUSS cycle on 09/28/17 at 8:25 AM for use in OR #27. The Director of Peri-operative Services confirmed at the time of observation that the documentation showed instruments brought to the Facility were processed in autoclave #4 and not taken to the Sterile Processing Department and sterilized as required per policy.

D. On 09/28/17 a review of IUSS Records for August 2017 showed Autoclave #4 was used for IUSS on 08/15/17. The documented cause for IUSS was that the instruments were brought in by a Sales Rep with the comments "None avail (available) sterile." Documentation showed the instruments were sterilized after being brought to the inner core and not taken to the Sterile Processing Department and sterilized as required per policy. The findings were confirmed on 09/28/17 at 1:57 PM by OR staff #1.

Based on observation, review of policy and procedure, and interview it was determined the Facility failed to prevent likely sources of infection in that: equipment used within the surgical suite had an accumulation of tape, tape/sticker residue (12 carts in Surgical Processing, 2 basin stands in OR #44); tape, tape residue and dust (6 of 6 carts used in surgery); two (#2 and #5) of six (#1-#6) rigid containers that held medication were broken and clean anesthesia cart stored immediately touching soiled linen cart. The failed practices did not ensure patients would be protected form likely sources of infection. Findings included:

A. Observation on 09/28/17 of the Surgical Processing/Central Sterile Department revealed 12 metal carts. The Manager of Sterile Processing identified the carts as clean and ready for use and stated the carts are used to transport surgical instruments. The carts had tape, stickers, and sticker/tape residue on the surfaces. The Manager of Sterile Processing confirmed the above findings on 09/28/17 at 10:38 AM.

B. Observation on 09/28/17 at 9:52 AM showed six of six (#1-#6) carts outside OR #44 with an accumulation of dust and tape residue on the outer surfaces. Cart #2 and #5 had cracks and open areas in the tray that contained medication on top of the cart. OR Staff #1 stated the carts and medication trays are taken into the OR for use in coronary artery bypass surgical procedures. If the cart contents are not used during the surgery, the carts are wiped down with disinfectant wipe and stored for use. The Director of Peri-Operative Services confirmed the findings at the time of observation.

C. Observation on 09/28/17 at 9:50 AM revealed two single basin holders in OR #44 taped together with a cloth type tape. The tape was porous and had the potential to harbor bacteria. The Director of Peri-Operative Services confirmed the findings at the time of observation.

D. Observation on 09/28/17 at 9:20 AM showed a clean anesthesia cart stored immediately beside and touching a soiled linen holder in the hallway outside OR #18. The Director of Peri-Operative Services confirmed the finding at the time of observation.