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Based on observation, interviews and document review, the facility failed to maintain appropriate infection control processes in the areas of disinfection of surgical instruments.

This failure created the potential for patients to be at risk for health care acquired infections.

FINDINGS:

POLICY

According to policy, Decontamination of Instruments and Devices, a neutral pH enzyme pre-soak, prepared in accordance with the manufacturer's instructions for use, is used to loosen protein and lipid soils.

REFERENCE

According to Prolystica 2X Concentrate Enzymatic Presoak and Cleaner, dilute 1/8 to 1/2 fluid ounce per gallon of warm water.

According to the Association of Operating Room Nurses (AORN), Guidelines for Perioperative Practice, 2015:

Recommendation IX (page 626), Surgical instruments and equipment should be cleaned and decontaminated according to the manufacturer's validated, written instructions for use.

1. The facility staff responsible for the disinfection of surgical instruments failed to follow manufacturer's instructions for use of enzymatic detergent in the pre-cleaning of surgical instruments.

a) On 01/25/16 at 1:53 p.m., a tour of the sterile processing area of the surgical department was conducted with the Sterile Processing Technician (Tech #1) and Peri-Operative Nurse Manager (RN #2). Tech #1 explained the process of pre cleaning surgical instruments by stating s/he would use 1 ounce (oz) of enzymatic solution in 1 gallon of water. This was in contrast to the manufacturer's instructions which stated to use 1/8 to 1/2 ounce of enzymatic solution per gallon of water.

b) On 01/26/16 at 10:21 a.m., an interview was conducted with the Peri-Operative Nurse Manager (RN #2), who stated the facility's expectation was to follow manufacturer's instructions when pre cleaning surgical instructions with enzymatic solution.