HospitalInspections.org

Based on observation and interview the facility failed to ensure that contracted staff sanitized their hands before and after patient assessments in the preoperative area for one (#2) of one patients observed for pre-operative care out of a total sample of 15, and failed to ensure that the rubber diaphragms of intravenous medication vials were disinfected before use for one (# 1) out of a total of 3 Surgical Anesthesia medication preparation observations, out of a total sample of 15, resulting in the potential for transmission of infection with the potential to effect all five patients cared for by these providers on the date in question. Findings include:

On 6/12/18 at approximately 0937, Certified Registered Nurse Anesthetist (CRNA) Staff I was observed preparing syringes of anesthetic medications for Patient #1's surgery at the Anesthesia cart in the operating room. Staff I opened multiple vials of intravenous medications and draw them up into syringes for use during surgery. Staff I did not disinfect the rubber diaphragm of the medication vials after removing the plastic caps on new vials. When asked, Staff I said that it wasn't necessary to disinfect them because they were sterile as they were just opened.

On 6/12/18 at approximately 0940, the Chief Nursing Officer Staff A, who was present during this observation stated, "(Staff I) hasn't been in-serviced on this yet. Medication vial diaphragms aren't guaranteed to be sterile when the vial is opened, so they have to be disinfected with alcohol before the medication is drawn up."

On 6/12/18 at approximately 1200, Contracted Neurotechnician, Staff S was observed entering Patient #2's pre-operative room area without sanitizing his hands. Staff S did not sanitize his hands and proceeded to apply leads and lead wires to various parts of Patient #2's body. Staff S then left the patient area and the pre-operative room without sanitizing his hands and began to type on his computer. Staff S was asked about hand sanitizing before and after Patient #2's care and said that he forgot to do it.

On 6/12/18 at approximately 12:15 Staff R, Staff K's Nurse Practitioner (NP) observed entering Patient #2's pre-operative room area without sanitizing her hands. Staff S did not sanitize her hands and listened to Patient #2's heart and lungs. Staff S then left the room without sanitizing her hands. When asked if she had sanitized her hands before and after assessing Patient #2, Staff R said, "I forgot. I'll do it now, thank you."

On 6/12/18 at approximately 1450, CRNA Staff U was observed entering Patient #2's pre-operative room area with out sanitizing her hands and then preformed a pre-operative anesthesia assessment for Patient #2. Staff U then left the area without sanitizing her hands and was observed handling the medication dispensing machine (pyxis) and the telephone without washing her hands.

On 6/12/18 at approximately 1500, Staff A, who was present during these three observations said, "They should know better. They're supposed to use the hand sanitizer before and after each patient, and before entering and before leaving the room. These were all contracted employees. They haven't attended our infection prevention inservices (trainings). We are responsible for them while they're in our facility, so we need to move forward on getting them inserviced."