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Based on observation, interview and record review, the facility failed to use proper cleaning solution ratios when cleaning endoscopes, store sterile medical supplies in clean proper area, separate and store patient food items from specimen items, and wear proper attire in designated areas.

Findings include:

1) On 11/2/11 in the morning, endoscopy procedures were observed in gastrointestinal (GI) room #1 and #2. Endoscopes used for the procedures were taken to the soiled utility room to be pre-soaked and cleaned prior to being transferred into another room for high-level disinfection.

The soiled utility room was a small enclosed area that was also being used as a storage area for medical supplies. Two to three people could fit in the room but it would be difficult to move around the room due to the size of the room and boxes of medical supplies stacked on the floor near one of the entrances. Packaged sterile supplies such as intravenous extension sets and nebulizer sets were being stored on shelves in the room just above a counter where the dirty scopes were placed prior to being placed in the sinks for soaking and cleaning. The technician indicated the medical supplies that were in boxes needed to be put away in a different area but confirmed some packages were left in the room and placed on the shelves for staff to come in and obtain when needed.

On 11/2/11 in the morning, the Interim Chief Nursing Officer (CNO) confirmed sterile packaged supplies should not be stored in the soiled utility room and on shelves.

2) On 11/2/11 in the morning, after an endoscopy procedure was completed the dirty endoscope was wrapped into a chuck and transferred into the soiled utility room and placed on a table. Approximately 6 to 8 inches above the table was a shelf that stored sterile packaged medical equipment. When the technician was manipulating the dirty scope, the endoscope and the technician ' s dirty glove continued to touch the under-side of the shelf due to the limited space. The dirty endoscope was then transferred to the sink and the chuck was thrown away. During the cleaning process the technician would place another chuck on the table and placed a newly soaked and cleaned endoscope on the same table before transferring the endoscope to another room for high-level disinfecting. The pre-cleaned scope that was placed on the table continued to touch the same areas on the under-side of the shelf where the dirty endoscope and dirty gloves touched.

On 11/2/11 in the morning, the Interim CNO confirmed the table had limited space due to the low shelving. The Interim CNO indicated the shelf would be taken down immediately and no sterile supplies would be stored in the soiled utility room.

3) On 11/2/11 in the morning, endoscope pre-soaking and cleaning was completed in the soiled utility room by the technician.

The technician placed the endoscope in the sink and placed one full pump of the Intercept solution into the sink. With the water filling the sink, the technician indicated she fills the sink with water 2 to 3 inches above the endoscope. There was no etched line in the sink to determine the amount of water in the sink and there was no measuring container to measure the amount of water to fill the sink. Also during the morning, the technician donned on a blue plastic apron when pre-soaking was being done in the dirty utility room. When the technician was completed with the soaking process she continued to walk in and out of the dirty utility room, into the procedure room, without taking her used apron off.

Intercept Next Generation Detergent was used as the pre-soak solution for soaking the endoscope in the sink. The label read:

- " ...For cleaning of fully immersible endoscopes, related accessories, surgical instruments, and other apparatus where blood, mucus, protein or other hard to remove soils are encountered, use Intercept at 1/3 oz./gal (ounces per gallon) of water(0.25% use concentration) with one full stroke of the hand-pump (1 oz.) to three gallons of water. If visible organic matter is present use 2/3 oz./gal of water ...which is two full strokes of the hand-pump (2oz.) to three gallons of water ... "

4) On 11/3/11 in the morning, the post procedure room where patients were taken after an endoscopy procedure was completed had a sink located in the room next to the bathroom. On the sink counter top was a clear container which had urine in the container. A staff nurse indicated a urine sample is sometimes obtained and placed by the patient on the counter next to the sink. Also on the sink counter-top next to the urine container were snacks and drinks to be given to patients after the procedures. The counter-top was not cleansed after the urine filled container was taken away.

On 11/3/11 in the morning, the Interim CNO confirmed it was not acceptable to place urine samples and snacks on the same counter-top next to each other.