HospitalInspections.org

Based on observation, interview and record review, the facility failed to maintain sterile practices in processing surgical equipment as evidenced by:

1) Staff in the decontamination room in central sterile processing department in street clothes.

2) Sterile surgical instruments not fully opened for sterilization.
Findings Include:

A) Record review

1) Facility policy "Decontamination of Surgical Instruments" Surgical Policy 011, dated 5/2019, stated "Surgical instruments will be decontaminated according to manufacturer's recommendations and in accordance with the Association for the Advancement of Medical Instrumentation (AAMI) standards. "once in the decontamination room the hospital care worker should always be wearing appropriate PPE."" The procedure states "Open the instruments fully...".

2) Policy review of American Association for the Advancement of Medical Instrumentation (AAMI) Standards, Comprehensive Guide to Steam Sterilization and Sterility Assurance in Healthcare Facilities, ST-79, 2017 stated "all personnel entering the decontamination, preparation, sterilization, and sterile storage areas should wear clean uniforms that are provided by and donned at the health care facility."

B) Observation

1) Observation during the initial hospital tour 3/16/22 at 1045, Environmental Services Director (EOD), Staff 11 entered the decontamination area of sterile processing wearing a short sleeve button up collared shirt and khaki slacks with red disposable surgical hat.

2) Observation of operating room supply closet 3/16/22 @ 1100 with Nurse Manager Staff 7, revealed sealed peel packages processed by six different staff members with the following instruments: 2 sets of "Metz"s, 3 sets of "Kaye Scissors", 3 sets of "Snitz" scissors. Two of the sets of mayo scissors in the closed position with rubber end protectors in place precluding them from full surface area sterilization in the open position.

C) Interviews

1) On 3/16/22 @ 1255, EOD Staff 11 stated "I didn't think I needed to wear PPE on the 'dirty' (decontamination) side." He further stated he "rarely has to go in the area unless" an environmental "work order is submitted." He confirmed that he saw the PPE available in the anteroom and signage posted on the door.

On 3/16/22 @ 1100 Central Sterile Supply Manager Staff 8 confirmed all staff entering area should have proper attire including surgical scrubs or protective jumpsuit and PPE which is donned in the anteroom. She verified the location of the supplies in the anteroom.

2) Interview 3/16/22 @ 1115 with OR Nurse Manager Staff 7 confirmed the instruments identified were in the closed position and should not be as it posed an infection risk due to suboptimal sterilization.