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Based on document review and interview, the central sterile processing staff in Surgical Services did not follow facility policy or standard of practice to ensure sterility of instruments. This has the potential to increase the risk of infection.

Findings include:

Review of Policy and Procedure titled " Functions of Sterilization " revised on 02/22/16 revealed when items are removed from the autoclave staff are to visually check the outside wrapper for dryness of packs, intactness of packs, and non-reactive chemical indicator. Each sterilization cycle should be mechanically monitored and the printer read out will be initialed by the sterilizer operator to verify that adequate time, and temperature and pressure were attained. In addition, a load card with chemical indicator will be processed with each steam sterilized load and attached to the sterility record.

Interview with Staff A, B, C, D, E, F and G, Facility Managers on 03/27/17 at 08:45 AM revealed on 2/19/17 Staff Y, Sterile Processing Technican pre-stamped the date 2/20/17 on surgical instruments that were washed, wrapped and ready for sterilization and placed them on an autoclave table that is used to place sterile items that had been removed from the autoclave. On 2/20/17 Staff I, Sterile Processing Technican noted the instruments stamped with current date (02/20/17) and released the instruments to the Wound Care Center. Autoclave completion cycle/sterility record and indicator color change were not checked prior to release of the instruments for use.

These findings were verified by Staff A, B, C, D, E, F and G, Facility Managers on 03/27/17 at 10:00 AM.