HospitalInspections.org

Based on review of the meeting minutes of the governing board and interview with the staff revealed that there was no review of the sterilization process or review of the hand sanitizing practices in the meal delivery system.

Findings were:

1. Between 10/21 (date new building opened) and 12/6/11 there were 41 biological indicators run with the autoclaved loads. The results either (+) or (-) were not document which load of the day that the biological indicator had been run with, nor was the load contents documented. The hospital policy "Biological monitoring of sterilization process requires accurate documentation" Although the biological indicators were run, they could not be traced back to individual loads. This was confirmed in interview with the nursing director on 12/7/11.

2. On 12/7/11 during the evening meal service dietary staff was observed to go to the room of the first patient and deliver the meal tray. Staff proceeded to move the patient's personal items from the bedside table and set up the meal tray for the patient. They staff member left the first patient room and proceeded to the next room with the meal tray for the second patient. The staff member did not wash hands, change gloves or use a hand sanitizer between patients. She proceeded to assist the second patient with their meal tray. Interview with the dietitian revealed that there is not a policy for dietary staff to clean or sanitize hands between patients. Interview with the administrative staff confirmed the above findings