HospitalInspections.org

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Based on record review, staff interview and observations, it was determined that the facility failed to comply with the Condition of Participation of Infection Control. This was evident by the facility's failure to ensure that staff complied with standard Infection Control Practices and facility Policies and Procedures to avoid potential sources of cross contamination which increase the risk of the spread of infection. This failure placed all patients at risk for exposure to Infectious Diseases.

Findings:

The facility failed to ensure that staff provided care in accordance with acceptable standards of Infection Control Practices in five (5) of five (5) Operating Rooms.

The facility failed to ensure that staff used acceptable standards of Infection Control Practices during the use of the Glucometer.

The facility failed to ensure that staff followed standard Infection Control Practices during patient care in four (4) observations.

The facility failed to ensure that staff followed Infection Control Policies and Procedures during the cleaning of medical equipment in three (3) observations.

The facility failed to ensure that the handwashing sink in Central Sterile was maintained.

See Tag A 749.

The facility failed to ensure oversight of the Preventive Maintenance Logs of the Endoscope Reprocessing System was performed by an assigned staff member to ensure that the Manufacturer's Guidelines were followed.

See Tag A 756.
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Based on observations, document review and interview, the facility failed to ensure that staff provided care in accordance with the acceptable standards of Infection Control Practices. This was evident in: a) five (5) of five (5) Operating Rooms (OR), b) during the use of Glucometers in two (2) observations, c) during patient care in four (4) observations, and d) during cleaning of medical equipment in three (3) observations. The facility also failed to ensure that: e) the handwashing sink in Central Sterile was maintained in good condition. These Infection Control breaches place all patients at risk for exposure to Infectious Diseases.

Findings:

a) Observations in the facility's Operating Room (OR) Suite during a tour between 11:45AM and 12:30PM on 07/09/15 identified the following failures by staff to comply with the facility's Policy on OR attire:

Review of the facility's Policy and Procedure titled "Attire, Operating Room / ASC (Ambulatory Surgical Care)", last revised 04/23/15, contained the following statements:

"Restricted Area: Includes the OR and Procedure Rooms, the Clean Core and Scrub Sink Areas.

Semi-Restricted Areas: Include ... Corridors leading to the Restricted Areas of the Surgical Suite.

Personal items are not allowed in the OR Rooms or Semi-Restricted Areas of the Perioperative Suites.

When scrubbed, earrings will be completely covered in disposable hats or hoods."

People in the Restricted and Semi-Restricted Areas "are required to wear full surgical attire and cover all head and facial hear, including sideburns and beards".

In OR #21 a Nurse had uncovered studded earrings. A staff member had approximately three (3) inches of hair above the nape of the neck and uncovered sideburns. Staff #6 (Anesthesiologist) wore her personal pocketbook with the strap across her shoulder and the bag on her right hip. In between adjusting the patient's drapes and equipment she repositioned the bag on her hip. Also, her earrings were uncovered. Staff #8 (OR Nurse) had a dark blue sweat jacket over her scrubs.

During an interview with Staff #6 (Anesthesiologist) on 07/09/15 at 12:20PM she stated that the pocketbook contained a pen, narcotic box and her cell phone. She keeps the bag in her locker.

During an interview with Staff #8 (OR Nurse) on 07/09/15 at 12:00 Noon, the staff member, who was observed wearing a jacket, stated she purchased it from the hospital and launders at home.

During an interview with Staff #2 (Regulatory Administration) on 07/09/15 at 2:15PM, the staff member stated that staff should not be laundering any OR clothes (blue sweat jacket) at home.

In OR #20 a Nurse had uncovered earrings. Another Nurse had uncovered sideburns. An Anesthesiologist had uncovered earrings.

In OR #18 a staff member at the sterile field had approximately four (4) inches of hair above the nape of the neck and uncovered sideburns. One (1) Anesthesiologist had approximately four (4) inches of uncovered hair above the nape of the neck and another Anesthesiologist had approximately two (2) inches of uncovered hair above the nape of the neck.

In OR #16 a Surgeon at the sterile field had uncovered hoop earrings. Another staff member had approximately three (3) inches of uncovered hair above the nape of the neck.

In OR #14 a Surgeon at the sterile field had uncovered hoop earrings.

Staff #7 was in the Semi-Restricted Area with his full thick beard uncovered.

During an interview with Staff #7 (OR Nurse) on 07/09/15 at 12:22PM, the staff member stated that he only has to cover his beard when he is in the OR Room.

Staff #23 (Anesthesia Technician) entered the Semi-Restricted Area with his beard uncovered.

During an interview with Staff #23 (Anesthesia Technician) on 07/09/15 at 12:25PM the staff member stated that he was going to the OR to set up the Anesthesia Cart and he only has to cover his beard when he is in the OR Room, not the Hallway (Semi-Restricted Area).

During an interview with Staff #4 (Nurse Manager OR) and Staff #5 (Assistant Director of Cardiac / Perinatal) on 07/09/15 at 12:30PM, they confirmed the findings.

b) During observation of Staff #9 (Nurse's Aide 15 South) at 11:55AM on 07/09/15, the staff member performed glucose testing using a Glucose Meter on Patient B. Prior to testing, without cleaning the patient's bedside table, she placed the Glucose Meter, gauze and lancet on the table.

While performing the procedure an error occurred with the device requiring the test to be repeated.

Without removing her gloves, performing hand hygiene, and donning gloves, she re-entered the test strip bottle with soiled gloves to remove a new test strip.

After performing the test she placed the dirty equipment on the bedside table and then proceeded to place the contaminated bottle of test strips in the carrying case.

She also placed the "dirty" Glucose Meter on the Docking Station at the Nurses' Station without cleaning it.

After removing the equipment from the table she did not clean the bedside table.

She did not perform hand hygiene and don gloves between clean and dirty tasks.

During an interview with Staff #9 (Nurse's Aide 15 South) on 07/09/15 at 11:55AM the staff member stated that "you only have to clean the Meter when it has been used in an Isolation Room". She was not aware cleaning of the Glucose Meter must be performed after each patient.

During observation of Staff #10 (Nurse's Aide 15 South) at 11:45AM on 07/09/15, she performed glucose testing using a Glucose Meter on Patients A and C.

She did not perform hand hygiene and don gloves between clean and dirty tasks.

Without cleaning the patients' bedside tables she placed the Glucose Meter, gauze, and lancet on the table. After performing the tests she placed the dirty equipment on the bedside table. After removing the equipment from the table, she did not clean the bedside table.

During an interview with Staff #5 (Assistant Director of Cardiac / Perinatal) on 07/09/15 at 11:55AM, the staff member confirmed the findings.

During an interview with Staff #1 (Director of Infection Control) on 07/10/15 at 1:30PM, the staff member stated that "they (Aides) should have wiped the (bed) table before they placed the equipment on it and they should have wiped down the table after they were done with the equipment. They should have set up a Dirty and a Clean Area. They did not follow Policy."

The facility Policy and Procedure titled "Point of Care (POC) Glucose Monitoring", last revised 06/05/15, stated the following: "cleaning of device must be done after each patient".



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During observation of Staff #21 at 12:15PM on 07/08/15, the staff member was observed placing a clean glucometer on a bedside table without wiping the table first prior to testing. The staff member punctured the patient's finger with the lancet and then placed the bloody cotton ball on the bedside table.

The staff member placed the dirty glucometer on a sink counter in a shared room. After cleaning the glucometer, she placed it back on a dirty sink counter. She exited the room without cleaning the sink counter and bedside table.

After exiting the room, she placed the dirty glucometer on a Docking Station at the nurses station.

This observation was made in the presence of Staff #22 (Director of Quality Management), who stated at the time of the observation "Yes, I saw that too."

The glucometer Policy and Procedure titled "Point of Care Glucose Monitoring", last updated 06/05/15, lacks step-by-step instructions to maintain good Infection Control Practices during the procedure.

c) During observation of Staff #16 at 11:30AM on 07/08/15, after removing a dirty Central Line dressing, the staff member failed to remove her gloves and perform hand hygiene prior to touching the outside of a sterile dressing change kit.

This observation was made in the presence of Staff #22 (Director of Quality Management), who confirmed the observation.

During observation of Staff #18 in an Isolation Room on the morning of 07/09/15, the staff member palpated an injection site prior to a subcutaneous injection, and then changed gloves without washing her hands between changes as per facility Policy.

This observation was made in the presence of Staff #22 (Director of Quality Management), who confirmed the observation.

The facility's Policy and Procedure titled "IC0003 Hand Hygiene", last revised 05/28/15, states in Section III:B:ii:b that hand hygiene is performed "prior to donning gloves, as well as after removing gloves", "when moving from a contaminated body site to a clean body site", and "before and after contact with...dressings."

During observation of Staff Members #20 and #24 in an Isolation Room between 11:30AM and 12:00PM on 07/08/15, the staff members placed a dirty tracheostomy tube on the patient's bed linen during a tracheostomy change, did not wash their hands the required length of time as per the CDC (Centers for Disease Control) guidelines.

During an interview with Staff #20, when asked the proper time to wash hands, replied "Two (2) minutes, we have to sing Happy Birthday". When asked how long she needed to sing, she replied "A lot of times".

This observation was made in the presence of Staff #22 (Director of Quality Management), who confirmed the observation.

The facility's Policy and Procedure titled "IC0003 Hand Hygiene", last revised 05/28/15, states in Section IV:C, that hand hygiene is to be performed "for 10-15 (ten to fifteen) seconds". This time is inconsistent with the CDC Guidelines of "20 (twenty) Seconds".

During observation of an epidural at 2:10PM on 07/08/15, Staff #19 was observed placing the patient's Medical Record on the sterile field on the Operating Room table during a time out. The staff breached the sterile field.

This observation was made in the presence of Staff #22 (Director of Quality Management), who confirmed the observation.

d) During observation of Staff #13 (Endoscopy Nurse's Aide) at 10:10AM on 07/10/15, the staff member did not perform hand hygiene for twenty (20) seconds as per CDC Guidelines after performing the pre/cleaning procedure (dirty) and placing the endoscope in the Automatic Endoscope Reprocessor (clean).

During observation of Staff #12 (Endoscopy Nurse) at 10:25AM on 07/10/15, the staff member did not wear appropriate PPE (Personal Protective Equipment), a gown and mask, when performing bedside cleaning of the endoscope.

During an interview with Staff #11 (Endoscopy Nurse Manager) on 07/10/15 at 10:30AM the staff member stated that "she (Endoscopy Nurse's Aide) should have washed her hands longer" and "he (Endoscopy Nurse) should have worn a face shield or mask and gown when he did the bedside cleaning".

The facility's Policy and Procedure titled "Endoscopy Endoscope / Accessory Cleaning and High Level Disinfection Utilizing Automatic Endoscope Reprocessor (AER)", last revised 05/15 directs staff to wear "chin length face shields, or chemical splash goggles, mask, gown, vinyl or nitrile gloves" when performing bedside cleaning of the endoscopy endoscope.

During observation of Staff #15 at 12:15PM on 07/10/15, the staff member was observed cleaning a ventilator with the same Sani-Wipe he used to wipe the heater element wire and gas tubing that were on the floor.

During an interview with Staff #22 (Director of Quality Management), the staff member stated, at the time of the observation, that "the machine is supposed to be cleaned from top to bottom".

The facility's Respiratory Care Policy and Procedure titled "Equipment Changes for Ventilators, Nebulizers and Humidification Devices", last revised 07/15, lacks instruction to clean the machine from top to bottom.



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e) On 07/08/15 at 2:30PM, the hand washing sink pipe in the Central Sterile Area was observed to be leaking water into a bucket which was overflowing at the time. As per concurrent interview with Staff #36 (Associate Director of Central Sterile and Supply), the staff member acknowledged the finding.
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Based on record review and interview, the facility failed to ensure that oversight of the Preventive Maintenance Logs of the Endoscope Reprocessing System was performed by an assigned staff member to ensure that the Manufacturer's Guidelines were followed.

Findings:

A review of the Daily Checklist for the DSD Edge Endoscope Reprocessing System revealed a list of daily tasks to be performed for daily start up and daily shut down.

An interview with Staff #11 on 07/09/15 at 1:30PM revealed that she is the Manager of the Department but that she has not been trained on the system and is not familiar with what to check for. She stated that the Nurses' Aides perform the cleansing of the scopes and if they need anything, or a machine needs attention, they would tell her and she would call Bio Engineering.

Review of the Document Filter Change Log for the DSD Endoscope Reprocessing System (Serial #73980246) revealed that the air filter was changed eleven (11) days after the date that it was due to be changed.

The Manufacturer's Guidelines document that the air filters should be replaced every three (3) months.

An interview at 3:30PM with Staff #2 revealed that the filter was changed within the time-frame, but that the staff member who recorded it dated it on the day she was advised, (eleven {11} days later).

An interview with Staff #11 revealed that there are no quality review checks to ensure that the disinfectant change, the water filter, water line disinfection vapor management filters, and reusable mesh disinfectant filters are changed in accordance with the Manufacturer's Guidelines. The staff member stated that the company is under contract to perform some of the filter changes and Bio Engineering takes care of others.