HospitalInspections.org

Based on observations, records reviewed and interviews the Hospital failed to consistently comply with their Infection Control policies and standards of care related to the use of bio-hazardous storage bags, disinfection of mobile supplies, management of multi-dose vials and care of the environment.

The Hospital's Exposure Control Plan, dated 6/22/18, indicated that leak proof single use bags are used for transporting specimens and any bag with a bio-hazard label must be placed into red bag waste.

1.) The Surveyor toured the Critical Care Unit and interviewed the Nursing Director of the Unit at 8:30 A.M. on 12/5/18. The Surveyor observed multiple unused blood tubes and an assortment of rolls of tape housed in bio-hazard bags. The Nursing Director said these items were not bio-hazardous and should not have been placed in bio-hazard bags.

The Surveyor toured the Peri-Operative Area and interviewed the Nursing Director of the Unit at 7:15 A.M. on 12/5/18. The Surveyor observed multiple emergency airway items housed in a bio-hazard bag. The Nursing Director said these items were not bio-hazardous and should not have been placed in bio-hazard bags.

The Surveyor observed a mobile transport cart being brought to Patient #7's bedside at 10:30 A.M. on 12/5/18 in the Critical Care Unit. Registered Nurse (RN) #5 said Patient #7 was to undergo an endoscopic procedure (endoscopy is a procedure that enables the examiner to view the esophagus, stomach, and small bowel using a flexible tube called an endoscope). The Surveyor observed multiple clean supplies housed in a bio-hazard bag on the workstation on wheels. RN #5 said there were only clean supplies on her cart.

RN #5 exited Patient #7's room at 10:55 A.M. at the completion of the bedside procedure. The Surveyor asked RN #5 about cleaning the workstation and the supply cart. RN #5 said that both items had been far enough away from Patient #7 and would not require cleaning. The Surveyor observed that the workstation on wheels was fully cleanable; however, the mobile supply cart had multiple paper products on the cart that would not be cleanable if splashed or soiled during a procedure. RN #5 said it was her practice to bring all items into the room in case anything was needed during the procedure.

The Surveyor toured the Endoscopy Unit and discussed the cleaning of the mobile equipment with the Surgical Director at 9:45 A.M. on 12/6/18. The Surgical Director agreed all items brought to the bedside are to be disinfected between patient uses.

3.) The Surveyor reviewed the process of handling multi-dose vials with RN #3 in the Critical Care Unit at 10:00 A.M. on 12/5/ 18. . RN #3 said the vials were checked for the expiration date and the dosage was drawn up according to the physician orders then checked with another Nurse prior to administration. RN #3 said a bar code sticker was placed on the syringe so that the medication could be scanned at the bedside without the multi-dose vial leaving the medication preparation area.

The Surveyor toured the Post Anesthesia Care Unit at 7:30 A.M. on 12/5/18 and interviewed RN #4 about the handling of multi-dose vials. RN #4 said the vials were checked for the expiration date and the dosage was drawn up according to the physician orders then checked with another Nurse prior to administration. Unlike the process described in the Critical Care Unit, RN #4 said the vial was brought to the patient's bedside to bar code scan and administer. This practice increases the risk of contamination of the multi-dose vials.

4.) The Surveyor observed two stanchions with a thick round heavy fabric attached to each stanchion in the Critical Care at 10:30 A.M. on 12/5/18. The Nursing Director of the Unit said that these were used for traffic control and to prevent visitors from cutting through the Nurses Station. The fabric barrier was touching the ground and the fabric material was not a smooth surface that could be adequately cleaned.