HospitalInspections.org

Based on observations (Pt. 1 and 2, Staff C and D), facility policy and procedure, staff interview, and national standards of practice, this facility failed to adhere to practices that would maintain an environment free of cross contamination to the patient in the endoscopy suite. Failure to adhere to infection control practices has the potential to affect all patients who receive endoscopic procedures in this facility.

Findings include:

The facility's policy titled, Hand Hygiene/Handwashing, previously reviewed on On 9-19-2012 at 8:48 AM states in part, "4. At a minimum, staff will wash their hands during the following times: ....After removing gloves."

According the to the Centers for Disease Control (CDC), a recognized authority on standards of practice in the health care setting, the following recommendations for hand hygiene were published in the October 25, 2002 edition of the WMMR (Weekly Mortality and Morbidity Report; www.cdc.gov ):
IV. Standard Precautions Assume that every person is potentially infected or colonized with an organism that could be transmitted in the healthcare setting.
Perform hand hygiene: IV.A.3.a. Before having direct contact with patients. IV.A.3.b. After contact with blood, body fluids or excretions, mucous membranes, nonintact skin, or wound dressings. IV.A.3.c. After contact with a patient's intact skin (e.g., when taking a pulse or blood pressure or lifting a patient). IV.A.3.d. If hands will be moving from a contaminated-body site to a clean-body site during patient care. IV.A.3.e. After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient . IV.A.3.f. After removing gloves.

On 11/7/2012 from 7:45 a.m. through 9:38 a.m. observations in the endoscopy suite were completed accompanied by Dir. A.

At 7:47 a.m. Pt. #1 was taken from the endoscopy procedure room to the recovery area after having completed the scheduled colonoscopy.

At 7:55 a.m. it was noted that the clean scope for Pt. #2 was already hanging on the endoscopy cart in preparation for Pt. #2's colonoscopy. This scope was hanging on the endoscopy cart prior to Pt. #1 leaving the procedure room. RN C explained that C put the scope there after spraying and wiping down the endoscopy cart with a spray disinfectant.

When questioned, and concerns expressed to RN C, about the practice of cleaning equipment while a patient is still in the room, and hanging clean equipment for the next patient while the previous patient is still in the room, RN C stated, "I don't know how that could be cross contamination. Its on wheels and I pull it over here."

RN C was referring to moving the endoscopy cart over to a sink area where dirty scopes are cleaned right after the scopes are removed from being inside a patient's colon. This area is approximately 5 feet from where the patient lays on a cart for the procedure.

In an interview with Mgr. B and Dir. A at 9:00 a.m. regarding this practice, Mgr B agreed that the equipment should not be set up until the previous patient has been removed from the room.

At 9:03 a.m. MD D entered the suite, did not wash hands, and proceeded to give pain medication and a sedative to Pt. #2 for the colonoscopy through Pt. #2's intravenous without cleaning the hub connectors.

After washing hands and applying personal protective equipment, MD D did a rectal check on Pt. #2, removed the glove from the right hand, put it on top of the clean field on the endoscopy cart and without washing hands applied another glove to the right hand and proceeded with the colonoscopy.

RN C set up equipment for obtaining tissue samples at approximately 9: 25 a.m. After setting up the equipment RN C removed gloves and applied a new pair without washing hands.

At 9:36 a.m. RN C again removed gloves and applied a new pair without washing hands.

At 9:45 a.m. during the exit interview with Mgr B and Dir. A, Mgr B stated that RN C's routine was disrupted with writer's presence and that was why the new scope was hanging up so early. Writer explained to Mgr B that the new scope was hanging prior to writer entering the room and interacting with RN C.

Dir. A confirmed these findings and stated that MD D should have washed hands and cleaned the hub connectors on the intravenous line prior to administering medication through it.