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Based on observations, records reviewed and interviews the Hospital failed to consistently adhere to infection control standards related to bronchoscope storage, the transport of soiled equipment and respiratory protection standards for three of three employees sampled.

1.) The Surveyor toured the Medical Intensive Care Unit at 8:40 A.M. on 6/15/17. The difficult airway cart was readily available to provide emergency equipment for the critical care patient experiencing a compromised airway. The cart was secured and the second draw was labeled as bronchoscope (a medical instrument that is passed into the windpipe in order to view the lungs).

Bronchoscopy Technician #1 opened the secured airway cart at 2:10 P.M. on 6/19/17. The bronchoscope was curled in the drawer wrapped in a green cinch sack wrapper. Bronchoscopy Technician #1 said the cart was opened every two weeks and the bronchoscope was reprocessed using an automated endoscopic reprocessor then stored in the drawer.

The manufacturer's directions for storage indicated that the scope must be hung in the storage area vertically and as straight as possible.

2.) The Surveyor further interviewed Bronchoscopy Technician #1 at 2:25 P.M. on 6/19/17. The Bronchoscopy Technician said that after the procedure the soiled scope was re-wrapped in the green plastic cinch sack and returned to the department for reprocessing.

The Hospital's Bloodborne Pathogen Exposure Control Plan, dated 4/12/17, indicated that containers for contaminated reusable items are color-coded or labeled with a biohazard warning label for transport.

3.) According to the CDC and Occupational Safety and Health Administration (OSHA) publication titled Hospital Respiratory Protection Program Toolkit, dated May 2015, indicated that fit testing is required for all users of respirators with tight-fitting face pieces (i.e. an N 95). The fit test ensures that, when donned properly, the selected brand and size of respirator fits adequately to protect the wearer from excessive inward leakage of contaminant through the face seal. The fit test must be repeated annually.

The Surveyor toured the Medical Intensive Care Unit (MICU) at 8:40 A.M. on 6/15/17. During the tour a number of negative pressure rooms used for airborne isolation were noted.
The Surveyor interviewed the Clinical Specialist in the MICU about the Hospital's fit test program. The Clinical Specialist said the fit testing was done as part of the onboarding for new employees and not repeated.

The Surveyor interviewed a Surgical Technician in Operating Room at 9:00 A.M. on 6/19/17. The Surgical Technician said she would be able to don an N 95 respirator and scrub in with a case of suspected or confirmed tuberculosis. The Surveyor reviewed the Surgical Technician's employee health records that indicated she had not been fit tested since 2015.

The Surveyor interviewed a Registered Nurse in the Endoscopy Unit at 11:00 A.M. on 6/19/17. The Endoscopy Registered Nurse said she would be able to don an N 95 respirator and assist with a case of suspected or confirmed tuberculosis. The Surveyor reviewed the Endoscopy Registered Nurse employee health records that indicated she had not been fit tested since 2004.

The Hospital's Tuberculosis Exposure Control Plan, 5/20/16, indicated that the highest risk departments (i.e. Respiratory Therapy) would undergo annual fit testing for the N 95 respirator.

The Surveyor reviewed Respiratory Therapist #1's employee health records that indicated he had not been fit tested since 2014.

The Surveyor interviewed the Hospital's Safety Officer at 8:00 A.M on 6/20/17. The Safety Officer said his department conducted most of the N 95 fit testing and the employee was told that in order to use the N 95 the employee would require fit testing within the past year. The Safety Officer said that staff might need additional education on fit testing.