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Based on observation, record review, and interview the facility failed to ensure the infection control system controlled infections by ensuring staff performed hand hygiene, processed hinged instruments in a manner to ensure sterility and cleaned equipment storage cabinets.

Findings include:

ICU (Intensive Care Unit)

Observation on 6/3/15 at 10:40 a.m. in ICU with Infection Control RN (Registered Nurse) #60 revealed RN #57 was providing care to Patient #4. RN #57 had on a pair of gloves and was flushing the patient's IV that was placed in her groin. RN #57 took off her gloves and without performing hand hygiene put on another pair of gloves to give medications through the patient's feeding tube. She removed those gloves and put on another pair of gloves without performing hand hygiene. She adjusted the flow rate on IV tubing and then opened a drawer to get an alcohol swab. She then injected medication into the patient's left upper thigh. RN #57 had RN #56 come into the room to help her pull the patient up in bed. RN #57 then changed gloves to perform oral hygiene without performing hand hygiene. Once she finished providing care and came out of the room, she used hand sanitizing gel.

During an interview on 6/3/15 at 11:40 a.m. with IC (Infection Control) RN #60 she said the hospital protocol was for hand hygiene to be performed with each glove change. She went to RN #57 and talked to her about the observations.

Record review of the facility's Policy and Procedure for Hand Hygiene dated 2/13 revealed the following:

"PURPOSE:

Hand hygiene reduces the risk of infection transmission from patient to patient and from patient to healthcare provider. This policy outlines hand hygiene requirements...

PROCEDURE:

A. Indications for hand washing and hand antisepsis:...

· Prior to donning gloves and after removing gloves..."


Sterile Processing

Observation on 6/4/15 at 11:00 a.m. in Sterile Processing with Infection Control RN (Registered Nurse) #60 of individual sterilized packaged instruments revealed hinged hemostats and scissors were not in the open position. One of the hemostats was ratcheted (locked). Some of the hemostat tips were touching. There were no inserts or products used to ensure the instruments stayed in the open position to be processed.

Interview at this time with Supervisor of Sterile Processing #62, he said the hemostats were left unratcheted, but he could see the tips were not in the open position. He said he could put tip protectors on the tips of the hemostats to keep them open. When he was asked about the scissors, he asked what could be used to keep them open.

On 6/4/15 at 2:55 p.m. Quality Assurance (QA) Manager #51 was asked for a Policy and Procedure for sterilizing single wrapped instruments. At 3:00 p.m. QA Manager #51 said Director of Operating Room #61 said there was no Policy and Procedure because it was a Standard of Practice to sterilize hinged instruments in the open position. She told him that hinged instruments were put on stringers to keep them open in instrument sets.

Record review of the AORN (Association of periOperative Registered Nurses) Perioperative Standards and Recommended Practices 2012 Edition on page 522 under Recommendation XII revealed the following:

"XII.c. Instruments with hinges should be opened ...Sterilization occurs only on surfaces that have direct contact with the sterilant...

XII.c.1. Instruments should be kept in the open and unlocked position using instrument stringers, racks or instrument pegs designed to contain instruments...."


Endoscopy Suite

Observation on 6/4/15 at 11:15 a.m. in the Endoscopy Suite revealed there were two procedure rooms. A patient was in Procedure Room #1. The high level disinfection room had both the dirty and clean area in one room.

Interview at this time with Endoscopy Manager #63, he said the endoscope processing machines were wiped off with sanitizing wipes after the dirty scopes were put inside to process. Once the process was completed, the scopes would be removed from the machines and placed in the storage cabinets as part of the clean process.

Further observations of the endoscopy storage cabinet in the hallway revealed a scope was hanging in the cabinet. The white bottom of the cabinet had orange colored swirls. There was a thin, long, black string like item on the bottom of the cabinet.

Further interview at this time with Endoscopy Manager #63, he said the orange swirls were stains that could not be removed. When he was asked how anyone could tell if the scopes were dripping discolored liquid from the present stains, he said he saw the point. He said the long black item was a hair. He said he did not have a cleaning schedule for the cabinets, but just cleaned them when it was needed.

Observation at this time of Procedure Room #1's scope storage cabinet revealed brown colored substance on the top white multiple hanging receptacles. There was an accumulation of dust on the bottom of the cabinet. In Procedure Room #2 the bottom of the scope storage cabinet had a layer of debris that included a lump of black dust.

On 6/4/15 at 2:55 p.m. Quality (QA) Manager #51 was asked for a Policy and Procedure for cleaning the endoscopy cabinets. At 3:00 p.m. QA Manager #51 said Director of Operating Room #61 said there was no Policy and Procedure for cleaning the endoscopy cabinets.