HospitalInspections.org

Based on observation, interview and document review, the hospital did not ensure (1) that used medical instruments were in a closed impervious container when transported from the facility's operating room (OR) to the sterile processing department (SPD) and (2) that SPD's sterilizers had quarterly preventative maintenance (PM) according to the manufacturer's instructions. Failure to adhere to adequate infection control practices with the transport and sterilization of used medical instruments can result in patient harm.

Findings pertinent to (1) include:

-- Per observation on 6/26/2023 at 1:25 pm, Staff A, Surgical Technologist and Staff B, Surgical Technologist, were transporting two carts loaded with used medical instruments towards the OR's soiled utility room elevator. The instruments were not stored within impervious containers or a covered cart.

-- Per review of hospital policy and procedure (P&P) titled "Traffic Patterns in Surgery," last reviewed 3/15/2023, "soiled supplies, instruments and equipment for reprocessing and trash and soiled linens should be contained in a closed impervious system or an enclosed cart."

-- Per interview of Staff C, Perioperative Services Director, on 6/26/2023 at 1:26 pm, he/she acknowledged the above findings.

Findings pertinent to (2) include:

-- Per observation on 6/26/2023 at 1:55 pm, 2 of 2 Getinge sterilizers in the SPD were due for preventative maintenance on 4/2023.

-- Per interview of Staff D, SPD Manager, on 6/26/2023 at 2:00 pm, he/she confirmed the above findings and stated that the sterilizers are supposed to have preventative maintenance quarterly according to their manufacturer's instructions.