HospitalInspections.org

The infection control officer or officers must develop a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel.

Based on observations and staff interviews, the facility failed to ensure the following:
1. Bags of intravenous solution were used for only one patient and not as a source of flush solution for multiple patients.

a) On 06/12/2012 a tour of the facility was conducted by two state surveyors. In the computed tomography (CT) room there was a 500 ml bag of sterile water dated 06/09/2012 with connecting tubing and a buff cap attached at the end hanging from an intravenous pole. The bag was approximately ? full. It was removed immediately by radiology personnel.

b) During brief discussions with the radiology department manager and staff member responsible for the CT room, no one could explain why the bag was there, for what reason it had been used, or for whom it had been used.

2. Medication administration tubing and connectors were used for only one patient.

a) During the tour including the Radiology and Emergency departments, there were multiple instances of oxygen connecting tubing attached to oxygen outlets and dangling at patient stations. There were no dates noted on the tubing providing information as to how long the tubing had been open at each station or how many different patients had used the tubing.

b) Discussions with personnel in each of these locations revealed that they did not think individual connecting tubing was necessary for each patient because fresh oxygen tubing was attached to the connecting tubing and leading directly to the patient ' s nostrils.

3. Nebulizers used in treatment of patients were rinsed and dried between uses on the same patient per the Centers for Disease Control and Prevention (CDC) guidelines.

a) On 06/13/2012 at 10:30 a.m. the respiratory therapy manager was interviewed and asked about nebulizer cleaning. S/he stated that the nebulizers were air dried and bagged until the next use on each patient. In order to help prevent healthcare-associated pneumonia and other lower respiratory infections, the CDC advises the following cleaning procedure as a class 1A recommendation (strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies): nebulizers be rinsed with sterile water or tap water followed by an isopropyl alcohol rinse and dried thoroughly between uses on the same patient. The manager stated s/he would immediately institute the new protocol and ensure all staff, including nurses and respiratory therapy personnel who administer these treatments, were trained appropriately.