HospitalInspections.org

The Critical Access Hospital (CAH) reported a census of one inpatient. Based on observation, manufacturer's guidelines review, policy review and staff interview, the infection control officer failed to develop an active infection control system to identify, report, investigate, monitor, and implement infection control precautions for one of one observed cleaning of a colonoscope and one of one observed cleaning of the procedure room. The failure to perform high level sterilization for critical equipment such as colonscope and failure to follow manufactures instructions with disinfectants used for surface cleaning placed patients who received a colonoscopy and care at risk for healthcare associated infections.


Findings include:

- The CAH's Infection Control Plan reviewed on 5/15/12 at 3:45pm directed "...Surveillance methods will be used to assess the quality of patient care and hospital support activities to promote effective infection control practices...".

- Administrative Staff A and staff B interviewed on 5/15/12 at 3:05pm verified they were responsible for the management of the infection control program. Staff B acknowledged they lacked a formal surveillance program with criteria for staff and environmental practices observing breaches in infection control. Staff B's infection control surveillance is based on patient assessment, antibiotic use, and employee illnesses only.

- The manufacturer's guidelines for " Endozime " (an enzymatic cleaner that removes microscopic particles) reviewed on 3/16/12 at 9:05am directed " ...Dilution one-fourth ounce per gallon of water ... ".

- The CAH's policy titled "Endoscope Cleaning, Disinfection, and Sterilization" reviewed on 3/16/12 at 8:45am directs staff to "...Immerse the endoscope and all channel irrigator into the disinfectant solution...".

- Staff C observed on 5/14/12 at 1:40pm cleaning the colonoscope used on patient #31. Staff C brought the colonoscope into the cleaning room, placed an unmeasured amount of "Endozime" into the sink and filled the sink with an unmeasured amount of water. Staff C placed the colonoscope in the sink and cleaned the colonoscope. Staff C filled a white tub with "Metricide 28" then placed the colonoscope in the disinfectant solution. Observation of the scope revealed areas of the scope not totally submerged in the solution and not disinfected.

Staff C interviewed on 5/14/12 at 2:00pm acknowledged they did not measure "Endozime" or the water placed in the sink. Staff C acknowledged they were unaware the "Endozime" required a ratio of one-fourth ounce to one gallon of water to be an effective cleaning solution for the colonoscope. Staff C acknowledged they failed to totally submerge the colonoscope into the "Metricide 28" to disinfect all areas of the colonoscope.

- The manufacturer's guidelines for the use of the "Quat-Stat SC" disinfectant cleaner, reviewed on 5/16/12 at 8:45am, directs "...contact time...use a 10 minute contact (wet) time for disinfection...".

- Staff B observed on 5/14/12 between 2:30pm and 3:30pm cleaned the procedure room after a colonocopy. Observation revealed the following breaches in infection control practices regarding disinfectant wet time per manufacturer's recommendation. For example:

Staff B using "Ouat-Stat SC" disinfectant cleaner, cleaned the cautery machine (used to stop bleeding during surgery), Endoscope monitor/viewer, and suction machine. Staff B failed to assure the surfaces remain wet for the required 10 minutes for disinfection.

Staff B interviewed on 5/14/12/12 at 3:30pm acknowledged the surfaces failed to remain wet the required 10 minutes for disinfection.

The CAH failed to develop an active infection control system to identify, monitor, and implement infection control practices.