HospitalInspections.org

Based on review of the Association of Perioperative Registered Nurses' (AORN), Cidex OPA manufacturer's recommendations, hospital documents, observation and staff interviews, it was determined the hospital failed to require that the ultra sound equipment and labor and delivery environment were maintained in a sanitary condition as evidenced by:

1. Failure to follow manufacturer's recommendations for high level disinfection in the Medical Imaging; Ultra Sound (US) Department; and

2. Failure to monitor the sterile field in the Labor and Delivery suite.


Findings include:

1. "Cidex OPA" directions for high level disinfectant use revealed: immerse for " a minimum of 12 minutes at 20 degrees C (68 degrees F) or higher to destroy all pathogenic microorganisms.

Review of the ultrasound Cidex OPA Log failed to reveal the immersion time or the temperature of the Cidex solution.

The Radiology Manager confirmed the above findings during an interview conducted 05/14/14.


2. AORN Perioperative Standards and Recommended Practices For Inpatient and Ambulatory Settings 2014 Edition; Recommended Practices for Sterile Technique pgs. 89 and 105 requires: "...creation and maintenance of sterile field can directly influence patient outcomes...All individuals...have a responsibility to provide a safe environment for patients... Sterile fields should be constantly monitored...subject to unrecognized contamination...if left unobserved...."

Observations made during the tour of the Labor and Delivery department on 05/13/14 noted Labor rooms 2502, 2504 and 2505 with a table covered with a blue drape outside each room in the hallway.

The Clinical Manager and RN #34 confirmed during an interview conducted 05/14/14 that the tables contained a sterile delivery set-up including sterile gown, instruments, drapes, cord clamp and bulb syringe. The tables were covered with a sterile sheet.

The nurses confirmed the department sets the table up when the patient reaches about seven centimeters dilated. The sterile tables are moved into the LDRs (labor delivery recovery) when the patients are about to deliver.

The Clinical Manager identified that she felt the tables were less likely to be contaminated if left in the hallway. The CM also identified the tables were in better view by the staff in the hallway and less possible contamination by the patient's families.