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Based on observations and staff interviews, the Hospital Infection Control Officer failed to consistently enforce hospital policies that governed the control and prevention of infection. Specifically, implementation of policies for cleaning and storage of patient equipment.
Findings included:

1. Observations of the main corridor in the Operating Room (OR) Suite, and interviews with Infection Control Officer (ICO) #2, the OR Assistant Coordinator, and the OR Educator at 8:45 A.M. on 10/17/2011, revealed two areas (OR #7 and the Vendor Storage Area) in which supplies and equipment were stored in manner that created a risk for cross-contamination, as follows:

A. Interviews with the OR Educator and OR Assistant Coordinator at 8:45 A.M. on 10/17/2011, revealed that OR #7 was used to perform high risk endoscopic procedures [procedures performed with a rigid or flexible tube equipped with a light delivery system to illuminate the hollow organ or cavity under inspection, e.g., colonoscopy (view the colon), bronchoscopy (view the lungs), gastroscopy (view the stomach)], on patients who required anesthesia. However, the room was also used to store OR equipment.

Observations during the interviews revealed that OR #7 was cluttered with supplies and equipment, all along the perimeter of the room, limiting the size of the room by up to three feet from the walls into the center of the room. Accounting for the equipment, the room, which measured approximately 24 by 16 feet, was reduced to approximately 12 by 10 feet.

The equipment stored in OR #7 included: one anesthesia machine; one anesthesia chair; one automated medication dispensing system with refrigerator (for refrigerated medications); one anesthesia supply cart; one endoscopy video stack with attached table to place instrumentation for procedures; one three-tiered endoscopy supply cart; two portable computers; two large, two-tiered computer tables [one table contained two boxes of gloves, one container of disinfectant wipes, multiple OR towels, several sets of compression boots, and a portable laptop computer; the second table contained a pillow, electrocardiogram monitoring leads, a patient transfer device (to move the patient from the stretcher to OR table), and a box of oxygen tubing]; a portable monitor for specialized endoscopic procedures; one electrocautery machine; a linen and a trash receptacle; a hand wash sink in the rear left corner of the room; two light sources; two ring stands; two radios; a foot stool; a procedure chair, two, ten gallon, needle/sharps biohazardous waste containers; a three-tiered linen cart with blankets, patient gowns, and sheets; and a third table containing a patient positioning device.

Additionally, staff stored the two, ten gallon, needle/sharps biohazardous waste containers immediately between the clean handwash sink and the clean linen cart, creating a risk of cross- contamination of the linen and handwashing sink.

According to interview with Endoscopy RN #1 at approximately 10:00 A.M. on 10/17/11, all unnecessary equipment is removed from OR #7 before the start of endoscopic procedures, to reduce the risk of cross-contamination of equipment.

However, observation of two, endoscopic procedures in progress (one at 11:00 A.M. on 10/17/11, and one at approximately 2:00 P.M. on 10/17/11) with ICO #2, revealed that all the above equipment and supplies remained in the room during the procedures.

Observations of the endoscopic procedure that took place at approximately 11:00 A.M. on 10/17/11, revealed three Endoscopy staff, one operating physician, one anesthesiologist, one family member, and the patient on a stretcher, all crowded into the small 12 by 10 foot work space. Movement around the operating stretcher was limited, increasing the risk of cross- contamination.

B. Observation of the Vendor Alcove and interviews with ICO #2, the OR Educator and the OR Assistant Coordinator at approximately 9:30 A.M. on 10/17/11, revealed that the alcove was located in a high traffic area and was cluttered with equipment and instrumentation supplied by vendors (personnel from outside companies), in addition to hospital-owned equipment. The area, which measured approximately 8 feet wide by 12 feet long, contained the following: three plastic boxes, measuring approximately 3 feet long, 1.5 feet wide, and 2 feet high that contained instruments for a total hip replacement surgery; a cell saver (device to return the patient's blood during a surgical procedure); a four-tiered cart, approximately five feet long and five feet high, used to store vendor supplies and instruments for bariatric surgery (weight reduction surgery); a copy machine; a power injector machine used to inject dye in vascular surgery cases; a large floor-model microscope used for plastic surgery; and a floor-model light source with an attached endoscope (a rigid or flexible tube with a light delivery system to illuminate the hollow organ or cavity under inspection), used in ear, nose and throat (ENT) surgeries.

Interview with the OR Assistant Coordinator at approximately 2:30 P.M. on 10/17/11, confirmed that the ENT endoscope had been disinfected and was available for immediate use on a patient.

The equipment and supplies were not stored in a manner to reduce the risk of cross-contamination. Although the alcove had a vinyl curtain that could be drawn to close the area off from the corridor, the curtain was left open increasing the risk of cross-contamination. The corridor was the main access to the OR for patients, families, and visitors.


C. Observations of the Vendor Alcove on 10/17/11, with the OR Educator, OR Assistant Coordinator and ICO #2 revealed the power injector machine (a machine used to inject dye into a patient to identify blood vessels in a vascular procedure), had hand-written user instructions, secured by adhesive tape to the handle and the top of the machine. The tape and written instructions taped to the machine limited the ability of staff to effectively disinfect equipment after each patient use.



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D. Observations in the Critical Care Unit on 10/18/11 at 9:15 A.M. in an unoccupied patient room that had been cleaned and ready for use, and in the procedure/clean storage room, with the Nurse Manager (NM), revealed multiple pieces of cleaned equipment (e.g. computers on wheels and bedrails), had tape and tape residue on the equipment. This equipment not been completely cleaned after use.

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Based on observations, patient and staff interviews, and review of hospital policies, procedures, and cleaning schedules, the Infection Control Coordinator (ICO) developed a system for identifying, reporting, investigating, and controlling infections. However, the Hospital failed to ensure that staff consistently implemented hospital infection control protocols. Specifically, compliance with protocols and standards for use of personal protective equipment, aseptic technique (a method used to prevent contamination), and infection prevention in the environment of care. Findings included:

1. Observations in the Critical Care Unit (CCU) on 10/18/11 between 9-11:30 AM, revealed the hospital failed to ensure that Personal Protective Equipment (PPE) was consistently used in accordance with hospital policy and standards of care, as follows:

A. Two of four physicians (CCU Physician #1 and #2) observed on 10/18/11 between 9-11:30 AM, failed to secure their Personal Protective Equipment (i.e., tie the protective gown) when entering a patient's contact precaution room.

Four physicians were observed entering CCU Room #16, a patient contact precaution room. According to the hospital policy and the sign posted on the door to the patient's room, gowns and gloves must be worn upon entering the room. Although the physicians donned gowns, two of the four physicians (CCU Physician #1 and #2) failed to secure their gowns using the tie closures. CCU Physician #1 was observed bending over to examine the patient. Because the gown was not secured, it fell from the shoulders of Physician #1 and did not adequately cover the upper part of the physician's body. Physician #1 was observed using her gloved hand to pull up the gown that had fallen down from her shoulders, thus contaminating her white coat. According to the Nurse Manager, Physician #1 was a Resident Physician on a CCU rotation.

2. Observation in the Emergency Department (ED) on 10/17/2011 between 1:00 and 3:00 PM, revealed a physician failed to remove Personal Protective Equipment (PPE), i.e., gloves, immediately before leaving the patient's environment. ED Physician #1, was observed returning to the nurses station wearing gloves on two separate occasions. The physician removed the gloves and began to work at the computer in the nurses station, instead of removing the gloves upon exiting the patient's room and performing hand hygiene.

3. Observations on A2, a medical/surgical unit, with the Nurse Manager on 10/17/11 at 3:00 PM, revealed PPE (face protection) was not readily available for use by healthcare workers. Observation of two precaution carts revealed face protection was not included in the precaution carts. In order to adhere to the standard precaution, face protection must be readily available and located near the point of use.

4. The hospital failed to ensure a patient was properly draped during the placement of a peripherally inserted central catheter (PICC). A PICC line is a long, small, flexible tube that is inserted into a peripheral vein, typically in the upper arm, and advanced until the catheter tip terminates in a large vein in the chest near the heart. Because of the risk of introducing infectious organisms "full body drapes" are used to reduce the risk of cross-contamination.
Observations in the Interventional Radiology Room on 10/17/11 at 10:00 A.M., revealed a patient positioned and draped for a PICC insertion. The patient was positioned leaning towards her right arm where the PICC line was to be inserted. Although all the healthcare personnel in the room were wearing full barrier protection, including masks, the patient's face was left without a barrier, breathing/exhaling approximately 15 inches from the insertion site, increasing the risk of contamination of the site during the procedure.

According to interview with Hospital Intensivist #1 (physicians with training in critical-care medicine) on 10/19/11 at 9:15 A.M., full body drapes in the Critical Care Unit included covering the patient's face with a drape or providing a facemask during central catheter insertion.

5. The hospital failed to ensure staff adhered to hospital policy to maintain asepsis (condition free from germs, infection) during a Central Line (a catheter placed into a large veins in the patient's neck, chest or groin used to administer medication or fluids) dressing change, as follows:
Observation in the Critical Care Unit on 10/19/11 at 8:40 A.M. and interview with the Intravenous (IV) Therapy Nurse #1, revealed the nurse changed a dressing on a left subclavian (upper left chest vein) central line. The IV Nurse removed the existing subclavian dressing using clean gloves. However, the nurse did not perform hand hygiene as required before donning sterile gloves to reapply a sterile dressing. At the same time the dressing was changed, the IV caps were also removed. According to the IV Nurse, the hospital policy required a 30 second scrub to the IV port prior to replacement with new sterile caps. However, the IV Nurse only wiped the ports.

6. Observation on A2, a medical/surgical unit on 10/17/11 at 3 PM, revealed an Environmental Service Department (ESD) worker terminally cleaning a contact precaution room (decontamination of the bed, bedside cabinet, and general area of the patient care unit with a detergent/germicidal agent after the patient is discharged or transferred from the room). The ESD worker removed the cubicle curtains for cleaning, however, he did not remove the window curtains. According to interview with the Environmental Service Director on 10/18/11 at 7 AM, cubicle curtains are removed and cleaned after a patient is discharged, however, the hospital cleaning protocol did not include provisions for removal of window curtains for cleaning during terminal disinfection of a patient contact precaution room.


7. Observations and staff interviews in the Operating Room (OR) Suite between 8:30 and 11:00 A.M. on 10/17/11, revealed the following:

A. Interview with the OR Educator at approximately 8:45 A.M. on 10/17/11, revealed that the types of patient procedures performed in OR #7 included bronchoscopies, to test for suspected diagnoses of Tuberculosis (TB). However, according to interview with the OR Educator, OR #7 was not a negative pressure room (a negative pressure room has a ventilation system designed to maintain a flow of air into the room, thus limiting the flow of airborne contaminants from the negative pressure room to other parts of the facility).
Interview with Endoscopy RN #2, at approximately 10:00 A.M., revealed that OR #7 had the capability to be changed to a negative pressure room, when needed. Endoscopy RN #2 said that when performing bronchoscopies to test for TB, the staff would contact the hospital Maintenance Department and the Maintenance Department would change the room to a negative pressure air flow.

However, interview with the Director of Facilities on 10/18/11 at approximately 1:30 P.M. revealed that OR #7 and the OR corridor were both neutral pressure areas, neither positive nor negative pressure areas. The Director said that OR #7 could not be changed to a negative pressure room.

The hospital did not adhere to the CDC recommendation (Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings 2005) to "whenever feasible perform bronchoscopy in a room that meets the ventilation requirements for an Airborne Infection Isolation Room (AIIR)" to reduce possible exposure to TB during bronchoscopy (AIIR have 6 air changes per hour, a system to maintain the room under negative pressure at all times, direct exhaust of air to outside, however, if not possible air is returned to an air handling system or adjacent spaces if directed through HEPA filters).

B. Observations at approximately 11:30 A.M. on 10/17/11, with Infection Control Officer (ICO) #2, revealed that after leaving OR #2, the OR Educator and the Assistant OR Coordinator untied the top ties of their surgical masks, leaving the lower ties in place, and wore their used surgical masks hanging down around their necks, onto their scrub suits. The OR Educator and the Assistant OR Coordinator failed to remove the masks immediately upon leaving the patient environment (OR).

C. Observation in the OR Suite at approximately 10:45 A.M. on 10/17/11, revealed a used (contaminated) plastic bag of irrigation solution draining into a scrub sink in Substerile Room #1. Interview with the OR Educator revealed that the irrigation had been used during a surgical procedure, and that a staff member hung the bag in the clean scrub sink to drain. The OR Educator said that the contaminated bag of solution should not have been hung in the clean scrub sink. Observations also revealed that the contaminated scrub sink was not disinfected before being used by Surgeon #1 to perform a surgical hand and arm scrub at approximately 11:00 A.M.

D. Observations with ICO #2 at approximately 11:10 A.M., during an arthroscopic procedure, revealed that RN #1 failed to adhere to infection control standards of practice, as follows:

i. RN #1 did not wear the surgical mask according to policy. The mask was worn so the bottom two ties were not tied and the mask did not securely fit over the RN's nose and mouth. According to interview with ICO #2, the mask was not worn in accordance with hospital policy.

ii. RN #1 failed to remove gloves worn during patient care and perform hand hygiene, prior to typing on the computer keyboard. RN #1 typed on the keyboard wearing the contaminated gloves, thus contaminating the keyboard.

8. Observations in the Endoscopy Suite from 1:45 P.M. to 3:00 P.M. on 10/17/11, revealed the following:

A. Observation of the insertion of a patient's IV at 2:00 P.M., revealed that Endoscopy RN #1, disinfected the patient's skin and then fanned the IV insertion site with her hand, to dry the disinfectant, increasing the risk of cross-contamination.

B. Observations with ICO #2 at 2:15 P.M., revealed that Endoscopy RN #3, failed to remove gloves worn to provide patient care and perform hand hygiene, prior to touching the automated medication dispensing system to obtain IV medications for the patient. The RN accessed the automated medication dispensing system, removed two vials of medications, drew-up the medications into two syringes, and proceeded to administer the IV medications to the patient, all while wearing contaminated gloves. Additionally, the RN did not disinfect the automated medication dispensing system after it was contaminated by the RN's gloves.

9. Observations and interview with ICO #2, in the Pain Clinic between 3:05 P.M. and 4:00 P.M. on 10/17/2011, revealed the following:

A. Observations at 3:05 P.M. revealed that Pain Clinic RN #1 and Nurses' Aide #1, each failed to properly secure their mask around their nose and mouth. Both staff only tied the top mask strings, leaving the masks hanging loosely over their faces. According to ICO #2, the two staff did not adhere to infection control standards of practice in that the masks were worn in an ineffective manner.

B. Observations of medication preparation at 3:15 P.M. revealed that Pain Clinic RN #1 failed to follow the Hospital's Medication Administration Policy. After contaminating the alcohol wipe by dropping it on the bedside table three times, the RN used the same wipe to disinfect the rubber septum of four separate vials of medications, prior to drawing-up the medication. After drawing up each vial of medication into separate syringes, the RN handed the syringes to Anesthesiologist #1, who injected the medications into the patient's lower back.

10. Observations of the insertion of a urinary catheter in a patient in OR #5, and interview with ICO #2, at approximately 8:00 A.M. on 10/19/11, revealed that OR RN #2, failed to adhere to the hospital's skin preparation policy. When prepping the patient's skin (i.e., using an antiseptic solution to cleanse the skin), prior to insertion of the urinary catheter, the RN prepped the shaft of the patient's penis first, and then prepped the tip of the penis (catheter insertion site). The RN failed to prep the catheter insertion site first (tip of the penis) to reduce the risk of cross-contamination.

11. Observations of the Maternal Newborn Pavilion and interviews with the Manager of the Maternal Newborn Pavilion (MMNP) and ICO #1, at approximately 1:30 P.M. on 10/19/11, revealed that the cleaning schedule of the Nourishment Room was not consistently maintained.

Observations on 10/19/11 at approximately 1:30 P.M., revealed that: (1) the nourishment counter was dirty with a black substance; (2) the floor and door of the refrigerator was dirty with spillage; (3) the freezer contained a large amount of ice build-up; and (4) the refrigerator lacked a thermometer and temperature log to ensure food was stored at proper temperatures.

Interview with the Director of Facilities on 10/18/11 at approximately 1:30 P.M., revealed that a cleaning schedule was developed for all the refrigerators in the hospital. Review of the cleaning schedule with the Director of Facilities, revealed that the refrigerators were to be cleaned quarterly. According to the cleaning schedule, the last time the refrigerator was cleaned was approximately eight months prior to survey (February 2011).