HospitalInspections.org

Based on review of facility policy, observation, and interview, the facility failed to ensure a sanitary environment for one of two Rapid Infusers and one of two walls in the Sterile Processing Department (SPD); and failed to wear gloves and follow safe injection practices for one of three departments observed.

The findings included:

Review of facility policy " Hand Hygiene" last revised 2/15, revealed "...the wearing of gloves is mandatory for certain patient care and work activities based on OSHA's [Occupational Safety and Health Administration] Bloodborne Pathogens Standard and the hospital's Exposure Prevention Plan policies on Standard Precautions...wear gloves when contact with blood, body fluid, potentially infectious material, mucous membranes, and non-intact skin..."

Review of facility policy "Sharps Injury Prevention" last revised on 5/14, revealed "...Disposal...all sharps must be handled, removed and disposed of properly...contaminated sharps should be disposed of in a puncture proof, labeled, color coded and leak proof container...used needles must not be sheared, bent, broken, or re-sheathed by hand...non-safety knife blades and needles should be handled using a single handed method or approved device..."

Observation on 6/8/15 at 9:50 AM, in the Emergency Department (ED) Trauma Resuscitation Area, revealed one Rapid Infuser (device used to infuse intravenous fluids and blood products at a high rate) with red dried debris inside the pressure chamber of the machine. Further observation revealed red dried debris on the outside top of the machine.

Interview with the ED Nurse Manager on 6/8/15 at 9:51 AM, in the ED, confirmed the red dried debris was blood and confirmed the facility failed to clean the Rapid Infuser.

Observation on 6/8/15 at 3:05 PM, in the SPD, revealed dried red debris on the large wall above the area where contaminated instruments were decontaminated.

Interview with the SPD Director on 6/8/15 at 3:10 PM, in the SPD decontamination area, confirmed the dried red debris was blood which had splattered on the wall during the decontamination of instruments and "...should have been cleaned off the wall..."

Observation on 6/8/15 at 2:25 PM, in the main Operating Room (OR) #5, revealed a physician preparing to administer a Lidocaine injection (local anesthetic) to a patient. Further observation revealed the physician did not have gloves on the hands and injected the Lidocaine into the patient's wound, administered the medication into multiple sites of the wound, and the wound had blood draining from the injection sites. Further observation revealed after the injection was completed by the physician, the physician recapped the needle with a needle cover and did not have gloves on the hands.

Interview with the OR Nurse Manager on 6/8/15 at 2:30 PM, in the OR hallway, confirmed the physician failed to wear gloves during the injection and the wound had blood draining from the needle site injections. Further interview confirmed the physician recapped a dirty, used needle, with a needle cover, and failed to wear gloves during the procedure.

Interview with the Infection Control Preventionist on 6/8/15 at 2:35 PM, in the OR hallway, confirmed the physician failed to follow the facility's policy related to the wearing of gloves during a procedure and proper disposal of contaminated used needles.