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Based on observation, staff interview, and clinical record review, the hospital failed to ensure medication was administered in accordance to a physician's order for 1 of 35 patients (Patient 20) when the patient was given twice the amount of a blood pressure medication (to lower the blood pressure) instead of what was ordered. This failure had the potential to cause significant harm to patients receiving an incorrect dose of medication.

Findings:

During a medication pass observation on 7/26/11 at 9:13 a.m. on the second floor medical surgical unit, Patient 20 was observed receiving a dose of hydrochlorothiazide 25 mg. (milligram - a unit of measurement and this was a medication for treatment of high blood pressure) administered by Registered Nurse (RN) 3.

During an interview with RN 3 on 7/26/11 at 9:23 a.m. regarding the discrepancy, she acknowledged the correct dose of the hydrochlorothiazide for Patient 20 should have been 12.5 mg. and the hydrochlorothiazide 25 mg. tablet should have been halved to make a 12.5 mg. dose prior to administering the medication to Patient 20.

On 7/26/11 a review of the clinical record was conducted. The original physician's order dated 7/22/11 for Patient 20 revealed the hydrochlorothiazide order was written for 12.5 mg once daily.

Based on staff interview, record review, and administrative document review the hospital failed to ensure medication was ordered for 2 of 35 patients (Patients 21 and 22) in accordance to facility policy and procedures titled "Physician Order" dated 7/12/10 when:
1. Patient 21 continued to receive an operating room (OR) medication (a medication to lower the blood pressure) after being transferred to the Intensive Care Unit (ICU) when it should have been discontinued at the time of the transfer.
2. Patient 22 was not administered breathing medication (an inhalation treatment for chronic obstructive pulmonary disease) as prescribed by a physician. These failures had the potential to cause harm to patients receiving medications when medications were not administered according to hospital policy and procedures.

Findings:

1. On 7/25/11 at 3:13 p.m., a review of Patient 21's clinical record was conducted. The clinical record indicated she was receiving amiodarone (medication used to manage abnormal heart rhythms) drip every hour in the ICU. Further review of the physician order for Patient 21 with Registered Nurse (RN) 4 revealed that amiodarone was written while Patient 21 was treated in the OR. There was no new amiodarone order written for Patient 21 since the transfer admission from the OR to the ICU on 7/24/11.

In the interview with RN 4 on 7/25/11 at 3:42 p.m., she acknowledged that she was just following the written amiodarone drip order from the OR physician.

On 7/25/11 a review of the hospital policy and procedure titled "Physician Order" was conducted. On page 3 H., it read "All existing orders are automatically canceled and must be re-written...4. Patient transferred from one patient care service to another..."

2. A review of the clinical record of Patient 22 on 7/26/11 indicated that Physician 1 had written a medication order for Duoneb or ipratropium bromide/albuterol (an inhalation treatment for chronic obstructive pulmonary disease) for Patient 22. Further review of the MAR (Medication Administration Record) dated 7/26/11 to 7/27/11 revealed that there was no record of Duoneb being administered to Patient 22.

During the interview with the Respiratory Therapist (RT) 1 and the Charge Nurse Manager (CRN) 1 on 7/26/11 at 12:13 PM, the CRN stated she wasn't able to find the Duoneb order in her computer system. The Duoneb order was not transmitted to the RT (Respiratory Therapist) department by the unit secretary according to the RT 1. Both the RT 1 and the CRN 1 acknowledged that Patient 22 had not received any Duoneb inhalation treatment according to their record.

On 7/25/11 a review of the hospital policy and procedure titled "Physician Order" was conducted. On page 5 section E. Transcription of Respiratory Therapy Orders 2. Place order for Respiratory Therapy into computer and call or page Respiratory Therapy. The Duoneb order was not transmitted to the RT (Respiratory Therapist) department by the unit secretary according to RT 1.

Based on observation, staff interview, clinical records and administrative document reviews, the hospital failed to ensure patient safety when drugs were not distributed in accordance with applicable standards of practice and state laws such as hospital policy and procedure (Physician Orders dated 7/12/10; Protocol ("Adult Critical Care Glycemic Control - "); Standard of Practice (Malignant Hyperthermia Association of the United States), and State Laws (Title 22 Regulations) as follows:

1. Title 22 regulations were not implemented to provide portable emergency containers (for example, carts, kits) with accurate lists of medications on the outside covers; ensure all of the medication listed on the outside cover of the portable containers were present and were sealed by a pharmacist in the Yellow Zone of the Emergency Department (ED); ensure all of the medications in the Anesthesia Work Room were present as required by the Malignant Hyperthermia Association of the United States to treat cases of malignant hyperthermia, a potentially fatal condition unless rapidly and properly treated.

2. Hospital policies and procedures were not implemented to ensure that dosage adjustments for continuous intravenous (IV) infusions of insulin (lowers blood sugar) were made according to the hospital's protocol and the prescriber's orders for 5 of 35 patients whose record was reviewed. (Patients 11, 12, 13, 14, and 15)

3. Hospital policies and procedures were not implemented to ensure that preprinted orders for making changes in continuous intravenous administration of 13 high risk medications affecting blood pressure and heart rhythms were sufficiently detailed for nurses to adjust doses safely and consistently.

These failures had the potential to adversely affect the care and outcome for patients who required medications during medical emergencies and those who received continuous IV infusions of insulin and other high risk medications.

Findings:

1. On 7/25/11 at 1:25 p.m., RN (registered nurse) 2 was asked to find the list of medications on the portable emergency cart number 7 in the Yellow Zone of the Emergency Department (ED). RN 2 was unable to find the list of medications which was supposed to be on the outside cover of the emergency cart. The California Code of Regulations, Title 22, 70263(f)(2) read, "The emergency drug supply shall be stored in a clearly marked portable container which is sealed by the pharmacist in such a manner that a seal must be broken to gain access to the drugs. The contents of the container shall be listed on the outside cover and shall include the earliest expiration date of any drugs within."

On 7/25/11 at 2:20 p.m., the ED portable transport box ("crash cart") was inspected with the DOP (Director of Pharmacy). This emergency container was not sealed and had been opened four days previously on 7/21/11. It contained the emergency medication epinephrine (to increase heart rate and blood pressure). At 2:40 p.m., four portable emergency medication containers were observed on a shelf in the medication room in the Yellow Zone of the ED. The containers were not sealed and the lists of medications were not on the outside covers.

On 7/25/11 at 2:55 p.m., a portable malignant hyperthermia (MH) emergency cart was inspected with the DOP in the Anesthesia Work Room. Fifty-50 ml (milliliters) vials (containers) of sterile water were located on top (outside) of the cart. The cart also contained dantrolene (muscle relaxant), two-1000 ml containers of sterile water and other medications. The cart was not sealed.

The Malignant Hyperthermia Association of the United States (MHAUS) has published the standards for medications and equipment which should be quickly available to treat Malignant Hyperthermia (MH) (MHAUS Online Brochure, 1/27/10). MH is a rapidly fatal disorder (with high body temperature that in incompatible with life) which can result from the use of succinylcholine and volatile anesthetics such as halothane and enflurane. MHAUS has indicated that lidocaine (for irregular heart rhythms), calcium chloride (provides calcium), and 50 % dextrose (sugar) injections should be quickly available in addition to other medications. Lidocaine, calcium chloride, and dextrose injections were not located in the hospital's MH emergency cart. These three drugs were not on the list of medications on the outside cover.

On 7/25/11 at 3:40 p.m., a portable transport emergency kit was observed in the Post Anesthesia Care Unit (PACU) with the DOP. It did not have a list of the medications in the kit on the outside cover.

On 7/26/11 at 8:30 a.m., a portable neonatal emergency resuscitation kit was observed in the Pediatrics area with the DOP and MSS (Medication Safety Specialist). It did not have a list of the medications in the kit on the outside cover.

On 7/26/11 at 8:35 a.m., a list of medications on the portable emergency cart (crash cart) in Pediatrics was examined with the DOP and MSS. The list did not contain quantities of norepinephrine (increases blood pressure and heart rate). The list indicated next to succinylcholine (paralyzes muscles) that "MFG [manufacturer] unavailable - Replaced with Rocuronium [paralyzes muscles] 50 mg (milligrams)/5 ml." Quantities of the two drugs were not identified and it was unclear from the list which medication (rocuronium or succinylcholine) was in the cart.

On 7/26/11 at 9:25 a.m., the DOP said Materials Management personnel provided seals for drawers in emergency carts which contained medications. The DOP indicated that Pharmacy had a supply of seals for the top drawer which contained most of the medications. The other drawers also contained medications, mostly intravenous solutions, which Materials Management placed in the emergency carts after the cart had been used. Subsequently, Materials Management sent the cart to Pharmacy which would place their seal on the top drawer and the seal provided by Materials Management on the remaining drawers. The DOP agreed that Materials Management personnel should not have access to the seals because they could remove items from the cart and reseal it rather than having a pharmacist reseal it. Any pharmacist would not be able to ensure that the medication contents of the cart were complete and reflected the list on the outside cover when Materials Management had a supply of seals for the carts. The DOP estimated that the hospital had approximately 80 emergency carts with medications.

The hospital's policy and procedures ("Code Blue - Medications & Crash Carts") did not indicate that a pharmacist sealed the drawers below the top drawer. The top drawer contained most, but not all, of the medications in the carts. The policy and procedures read, "At...", all adult and adult/pediatric crash carts will be maintained by stockroom, keeping seals intact and checking expiration dates. Any used cart will be exchanged with a new one by stockroom and taken to pharmacy where the medication tray [in the top drawer] will be replaced and locked by pharmacy staff." Also, "At ..., crash cart locks are applied and monitored by Materials Management at... Each crash cart lock is numbered with access provided only to the Traction or Materials Management Department staff."

2. On 7/26/11 at 10:30 a.m., the medical records (nursing flow sheets) for 5 of 35 patients (Patient 11, 12, 13, 14, 15) were reviewed with Pharm (pharmacist) 1. All had received continuous intravenous insulin (lowers blood sugar) infusions during their hospitalizations. Their blood sugars were measured approximately every hour. Dosage adjustments in their insulin infusions were also made approximately every hour, when necessary, based on their blood sugar measurements. The adjustments were made based on hospital protocols ("Adult Critical Care Glycemic Control"). Changes in two doses for Patient 11 on 7/19/11 were not made according to the hospital's protocol and the prescriber's orders. Incorrect doses of insulin could cause hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar).

3. On 7/26/11 the Director of Pharmacy (DOP) provided preprinted prescribers' orders ("Vasopressor/Inotrope Infusion Orders-Adult Critical Care") for the following high risk drugs which can increase blood pressure, heart rate, or both: dobutamine, dopamine, epinephrine, norepinephrine, phenylephrine, and milrinone. The instructions for the nurse on these preprinted orders were for him/her to titrate (adjust) the intravenous (IV) infusion (administration) rate to maintain a systolic blood pressure or mean arterial pressure within a given range (for example 90 - 100 millimeters of mercury for systolic blood pressure). The given range is ordered by the prescriber. The instructions provide a starting dose and a range for dose rates adjustments which the nurse may make in order to maintain the blood pressure or mean arterial pressure within the indicated range. For example, the starting dose for norepinephrine could be 1 mcg (microgram)/kg (kilogram)/minute and the nurse thereafter could change the rate of the IV infusion anywhere from 1 to 30 mcg/kg/minute to maintain the blood pressure or mean arterial pressure within the given range.

Similar preprinted orders (Anti-Arrhythmic/Vasodilator Infusion-Adult Critical Care") were used for the following high risk medications which can lower patients' blood pressures or
change heart rhythms (for example, slow the heart rate and/or lower blood pressure): amiodarone, diltiazem, esmolol, nicardipine, nitroglycerin, and nitroprusside. These orders had blood or mean arterial pressure ranges or heart rate ranges for the nurse to achieve/maintain and had starting doses and infusion rate ranges for the nurse to use to maintain the patients blood pressures or heart rates. For example, the starting dose for nitroprusside could be 0.5 mcg/kg/minute and the nurse may thereafter change the rate of the IV infusion from 0.5 to 8 mcg/kg/minute to maintain blood pressure or mean arterial pressure or heart rate within a given range.

The above examples for norepinephrine and nitroprusside were provided on preprinted orders and only required the prescriber to place a check in a box next to the item (for example, starting dose and dosage range). Also the prescriber could select and write in different parameters for starting dose and dosage ranges. However, the orders did not provide sufficient instructions for the nurse to make IV infusion rate changes. For example, one nurse might change a nitroprusside infusion rate by 8 mcg/kg/minute and another might change it by 0.5 mcg/kg/minute for the same blood pressure reading. Likewise, there is a 30 fold difference in infusion rate changes a nurse or different nurses might make for norepinephrine for the same blood pressure reading. The instructions on the preprinted orders also did not indicate the frequency which changes in IV infusion rates should be made. One nurse might change the rate every minute or every five minutes or longer.

These high risk medications can cause severe adverse effects (for example, hypotension-very low blood pressure, heart arrhythmias) or an absence of desired therapeutic effects when administered to rapidly or too slowly, respectively. Incremental changes in infusion rates, either faster or slower, should be more narrowly defined and based on the potential ranges of blood pressures, mean arterial pressures, or heart rates which might be encountered. They would decrease the opportunities for increasing or decreasing the IV infusion rates by too little or too much. Defining the frequency rate changes should be made would prevent increasing or decreasing doses too often or too infrequently. Such changes would provide greater safety and ensure consistency of care by all nurses.

Based on observation, staff interview, and administrative document review, the hospital failed to remove outdated or otherwise unusable drugs from areas where they could have been administered to patients. These failures could have resulted in patients receiving medications which were not their labeled strength or were contaminated and had the potential to adversely affect patients' health.

Findings:

On 7/25/11 at 1:25 p.m., the medication room in the Yellow Zone of the Emergency Department (ED) was inspected with the DOP (Director of Pharmacy) and MSS (Medication Safety Specialist). A container of labetalol injection (lowers blood pressure), 100 mg (milligrams)/20 ml (milliliters) was in the room. The labetalol had been opened (partially used), but was not dated signifying the date it had been opened.

On 7/25/11 at 2:00 p.m., a Rapid Sequence Intubation Kit was opened in the Trauma area of the ED. The DOP was present. The Kit contained succinylcholine injection (paralyzes muscles), 20 mg/ml, 10 ml, which had an expiration date of 7/19/11. At 2:25 p.m., a drawer in Trauma 2 of the ED contained a bottle of proparacaine anesthetic eye drops (relieves pain/feeling in the eye), 0.5 %, 10 ml. The drawer also contained medical equipment.

Hospital policy and procedures ("Medications - Multi-Dose Vials") read, "Unless there is evidence of contamination, multi-dose vials [containers] with preservatives may be used: ... 2. until the manufacturer's expiration date or 28 days after opening, whichever comes first." Also, "It is the responsibility of the clinician ... to ensure that there is an expiration date on the product before use." Another hospital policy and procedures, ("Unit Inspection by Pharmacy") read, "...8. Non-drug items stored separate from drug items."

On 7/25/11 at 3:20 p.m., a warmer (warms solutions) between Operating Rooms three and four was observed with the DOP. The warmer contained 1000 ml normal saline (salt solution) irrigation solutions. A sign attached to the outside of the warmer read, "Keep under 104 degrees [Fahrenheit]" The temperature gauge on the warmer read 107 degrees Fahrenheit (F). The warmer also contained an opened (did not have a seal on it) sterile water irrigation solution which was labeled, "Do not use unless seal is intact".

On 7/25/11 at 3:40 p.m., a solution warmer in the Post Anesthesia Recovery Unit (PACU) was inspected with the DOP and the MSS. It contained normal saline and lactated ringers (salt solution) intravenous (IV) solutions which were dated 9/22 and 9/25 (no year indicated). The DOP said the hospital policy is for the solutions to be dated for 14 days in the future when they are placed in the warmers. RN (registered nurse) 1 said surgical technicians placed the solutions in the warmers and dated them.

The hospital's policy and procedures ("Warmers - Solutions and Blankets") read, "Intravenous fluids: a. Maximum temperature is 104 degrees F. b. Maximum time in warming cabinet is 14 days. c. Leave plastic over pouch on IV bags during warming." The IV solutions, therefore, were dated approximately 60 days in the future instead of 14 days.

On 7/26/11 at 9:05 a.m., two opened 500 ml containers of sterile water for irrigation were observed in Ultrasound. The containers were labeled for single use and should have been discarded after opening and partial use.

On 7/26/11 at 10:19 a.m. during an inspection of the fifth floor central medical surgical unit with Pharm 1, an intramuscular thiamine 1 ml syringe 250 mg/2.5 ml was found in the medication room refrigerator with an expiration date of 7/23/11. Pharm 1 acknowledged the syringe should be returned to pharmacy upon discharge of the patient from the unit or when the medication was expired.

Based on observation, interview and record review, the facility failed to ensure that kitchen food service practices protected patient foods from potential contamination, when kitchen staff did not observe proper sanitation techniques during temperature measurement at the trayline.

Findings:

On 7/26/11 at 9:15 a.m., Cook 1 was observed at the trayline of the grill area of the kitchen, preparing to take the temperature of the hot foods on the steam table. Cook 1 inserted the thermometer into the food from the first pan and kept it there for approximately 15 seconds and recorded the temperature of the food on the temperature log on the counter top. The cook was then observed wiping the residual food from the thermometer probe with a wiping cloth from the counter of the steam table, where at least two individual packets of alcohol wipes were also observed next to the wiping cloth. After wiping the probe, the cook proceeded to measure the temperature of the food at the next pan, documented the temperature of the food, wiped the probe again with the cloth and proceeded to the next pan.

In an interview on 7/28/11 at 9 a.m., the Assistant Director of Nutrition Services stated staff received orientation training and in-service training on the cleaning and sanitation of equipment which included food thermometers.

Review of the Infection Control policy of the "Nutrition/Dining Services", dated 6/13/2011 was reviewed on 7/26/11. The policy revealed employees were required to attend orientation and annual in-service training that include sessions addressing the cleaning and sanitation of equipment, as well as sources of foodborne illnesses. The policy contained the following documentation. "The temperature of solid foods will be tested in the center of the product using a calibrated, sanitized thermometer. The temperature of liquid and semi-liquid foods will be tested with a calibrated, sanitized food product thermometer, after thoroughly stirring the product."

Based on observation, staff interview and administrative document review, the facility failed to assure the safety and well-being of patients when the storage of water supply in the event of emergencies did not meet the needs of patients at the acute psychiatric unit. This failure resulted in the potential of not having adequate water supply in the event of an emergency.

Findings:

During a tour of the acute psychiatric unit on 7/27/11 at 3:45 p.m., observation of the store room housing the facility's emergency water revealed large and medium-sized clear, plastic bottles of water standing upright against the wall or stacked horizontally on rack shelves. To the left of the door were two empty five-gallon bottle standing upright on the floor and two empty five-gallon bottles stacked horizontally on rack shelves with four other bottles (three-gallon size) with water. Directly opposite the door were five empty five-gallon bottles and 11 full bottles of water at three gallons each, stacked horizontally on rack shelves. Available water, based on the amount on hand, was 45 gallons.

In an interview on 7/27/11 at 3:53 p.m., Clinical Nurse PD and the House Supervisor stated the emergency water supply was planned for 77 persons (patients, staff and visitors) for three days at three gallons per person. When asked about the amount of water that should be in the store room for emergencies and about the empty bottles of water in the store room, both staff members were unable to state how many gallons of water should be in the store room and to explain what happened to the water in nine of the bottles.

On 7/27/11 at 4:00 p.m., the Office Manager was asked about the empty bottles in the store room. The Office Manager stated the five-gallon bottles were used up in order to replace with three-gallon bottles, in order to prevent injury to staff as a result of carrying the heavier bottles. Office Manager further stated there were nine bottles of water at three gallons each, in her office to replace the water used up. The total amount of water used up was 45 gallons; the total volume available for replacement was 27 gallons, which is 18 gallons short of the amount being replaced.

On 7/27/11 at 3:56 p.m., the Clinical Nurse PD was asked to provide information on the emergency water supply from the facility emergency binder containing policies and procedures on emergency planning. The Clinical Nurse PD was unable to provide the information during the survey.

Based on observation, staff interview, and administrative document review, the hospital failed to ensure that the infection control officer developed and implemented policies and procedures governing control of infections and communicable diseases.
1. Failure to ensure that trash bags was securely closed before being placed in the trash chute, and that the trash chute was routinely cleaned.
2. Failure to ensure that clean linen was covered and stored separately from soiled linen.
3. Failure to ensure that 4 of 6 emergency supply carts were thoroughly cleaned after each use.
These failures placed patients at risk of receiving a hospital acquired infection.

Findings:

1. The hospital failed to develop a process for ensuring that the trash chute (chute where bags of trash were placed on the nursing units and transported to a collection dumpster in the basement), was routinely cleaned and that bags of trash were closed securely before being placed in the trash chute.

On 7/26/11 at 9 am, the trash chute located on the 10 th floor of the non-trauma nursing unit was inspected. After opening the trash chute door, it was noted that the door jam of the trash chute and the metal siding inside trash chute was covered with thick film of dirt and dried fluids.

During a concurrent interview, the Infection Preventionist (IP), stated that bags of trash were sent down the chute and collected in a dumpster in the hospital basement. The IP was asked if the trash chute was routinely cleaned. The IP replied, she was unsure if housekeeping staff routinely cleaned the trash chute.

On 7/27/11 at 10 am, the trash chute located on the 8 th floor on the non-trauma nursing unit was inspected. After opening the trash chute door, it was noted that the door jam and the metal siding inside trash chute was covered with thick film of dirt and dried fluids.

On 7/27/11 at 2 pm, the room in the basement where the trash collection dumpster was located was inspected. Upon entering the room, it was noted that bags of trash and loose pieces of trash were littering the floor. It was noted that the floor was wet with brown colored fluids. In addition, it was also noted that some of the trash bags collected inside the dumpster were not closed and loose pieces of trash were scattered about. The inside of the trash chute was inspected and revealed the inside of the trash chute was covered with a thick film of dirt and dried fluids.

During a concurrent observation, a housekeeping staff was observed picking up pieces of loose trash and placing the trash in the collection dumpster. During the observation, the housekeeper stated that nursing staff routinely placed open bags of trash in the chute causing trash and fluids to splatter inside the chute and scatter about the dumpster storage room floor.

At the same time an interview was conducted with the Environmental Services (EVS) Manager. The EVS Manager was asked if the hospital had a process ensuring that trash was disposed of in closed bags and for cleaning and sanitizing the trash chute. The EVS Manager stated that nursing staff were instructed that trash bags were to be securely closed before placing the trash bags in the chute. The EVS Manager also stated that he did not have a system in place for routine cleaning of the trash chute.

On 7/27/11 at 4 pm, the 2009, APIC (Association of Professionals in Infection Control and Epidemiology), text of Infection Control and Epidemiology, 3rd Edition, was reviewed. On page 100- 11, APIC ' s direction was, " Waste should be secured and closed before transport ... Although there are no guidelines on the frequency with which chutes should be cleaned, they should be cleaned on a routine schedule (usually at least daily) and whenever spills occur. The waste holding room should be cleaned at least daily ... "

2. The hospital failed to ensure that uncovered clean and soiled linen were not stored immediately next to each other. Storage of soiled linen immediately next to the clean linen, increases the risk of contaminating the clean linen.

On 7/26/11 at 11:45 am, the hospital linen storage area was toured. During the tour, it was noted that a large bin containing what appeared to be soiled linen was stored uncovered right next to wire shelves where clean linen was stored.

During an interview on 7/26/11 at 11:45 a.m., the Linen Services Manager confirmed the large bin contained mostly soiled linen. The Linen Services Manager stated he was not aware that soiled linen could not be stored next to clean linen. The Linen Services Manager verified that the department did not have a policy and procedure directing staff about the storage of clean and soiled linen.

On 7/27/11 at 4 pm, the 2009, APIC (Association of Professionals in Infection Control and Epidemiology), text of Infection Control and Epidemiology, 3rd Edition, was reviewed. On page 100- 8, APIC ' s direction was, " Clean and soiled linen must be stored and handled separately .... Clean linen should be stored in covered carts or enclosed cabinets .... "

3. The hospital failed to develop and implement policies and procedures ensuring that emergency equipment carts were thoroughly cleaned after each use.

On 7/26/11 at 11 am, the "Traction" Department, (an area where equipment is decontaminated and clean equipment stored), was toured. During the tour, the clean and ready for patient use emergency supply carts were inspected. It was noted that flat metal surfaces at the bottom of 4 of 6 emergency carts were covered with a film of dirt and dust.

During an interview at the same time, the Manager of the Traction Department stated after use, the emergency supply carts were returned to the department for decontamination and cleaning. The Manager of the Traction Department was asked about the process for ensuring that the entire cart was cleaned after use. The Manager of the Traction Department stated during the cleaning process only the top surface of the cart was routinely cleaned.

On 7/27/11 at 4 pm, the 2009, APIC (Association of Professionals in Infection Control and Epidemiology), text of Infection Control and Epidemiology, 3rd Edition, was reviewed. On page 100- 2, APIC ' s direction was, " EVS (environmental services), and infection preventionists need to form a partnership to maintain a clean environment. Infections preventionists can help educate personnel, advice on cleaning procedures and schedules, provide expertise on cleaning agents, assist in writing policies and procedures, and participate in performance improvement activities. "

Based on observation, staff interview, and administrative document review the hospital failed to ensure 3 of 3 semi-critical patient care equipment items (items that come into contact with mucus membranes) were high level disinfected (use of Cidex or Glutaraldehyde - used when material/instrument cannot be steam or gas sterilized) in accordance with manufacturer recommendations and stored in a manner that prevented contamination and bacterial growth after high level disinfection. This failure had the potential to place patients at risk for hospital acquired infections.

Findings:

1. On 7/25/11 at 10 am, a tour was conducted of the trauma room in the emergency department. During the tour the emergency supply cart was inspected. Inside the emergency cart a GlideScope (a piece of video equipment used to insert an artificial airway into a patient's lung), was observed.

At this time, the Charge Nurse was asked to explain the process for cleaning the GlideScope after use. The Charge Nurse stated that after use the GlideScope was cleaned using a purple top Sani-Wipe disinfectant wipe. When asked if any other form of disinfection was used the Charge Nurse replied, "No."

On 7/26/11 at 8 am, the hospitals' "Environmental Facility Cleanliness" guidelines dated 2/3/09 were reviewed. It was noted the Environmental Facility Cleanliness " guidelines contained no directions on how to clean and disinfect the GlideScope.

On 7/26/11 at 10 am, the manufactures' directions for cleaning and disinfecting the GlideScope were reviewed. The manufacturer directions were, " The GlideScope GVL is a non-sterile, reusable device. It is required that the GlideScope GVL is cleaned and disinfected after every patient use using a high level disinfection (method used to achieve sterilization for items that cannot be processed in a sterilizer) method.

2. On 7/25/11 at 10 am, a tour was conducted of the trauma room inside the emergency department. A metal suitcase was observed near the cart containing emergency equipment and supplies. Inspection of the contents inside the metal suitcase revealed a piece of foam material with the flexible endoscope looped inside the foam.

At the same time an interview was conducted with the Charge Nurse of the Emergency department. The Charge Nurse identified the flexible endoscope as a bronchoscope (a flexible tube with a light source that is inserted into a patient's lung). The Charge Nurse stated that after high level disinfection, the flexible endoscope was always stored in the metal suitcase.

On 7/27/11 at 1 pm, an interview was conducted with the Sterile Processing Department (SPD) Manager. The SPD Manager was asked to explain the hospital's usual practice for storing flexible endoscopes after high level disinfection. The SPD Manager stated that after high level disinfection, the flexible endoscopes were stored in a cabinet, by hanging vertically straight. When the SPD Manager was asked if he was aware that flexible endoscope in the emergency department was routinely stored coiled in a metal suitcase, he replied, "No, I wasn't."

On 7/27/11 at 4 pm, the "Perioperative Standards and Recommended Practices", published in 2011 by the Association of perioperative Registered Nurses (AORN), was reviewed. On page 420, under Recommendation IX, AORN recommended that, "Flexible endoscopes should be stored in a manner that protects the device from damage and minimizes microbial contamination." Under item IX.a., AORN recommended that, "Flexible endoscopes should be stored in a closed cabinet with venting that allows air circulation around the flexible endoscopes, internal surfaces composed of cleanable materials. Adequate height to allow flexible endoscopes to hang without touching the bottom of the cabinet ...When flexible endoscopes are hung in the vertical position, coiling or kinking is prevented, allowing any remaining moisture to drain out of the endoscope and decreasing the potential development of an environment conducive to microbial growth in the endoscope. Proper storage facilitates drying and decreases potential for contamination ..."

3. On 7/27/11 at 9:20 am, a tour was conducted of the ultra sound department. During the tour, three endo-vaginal ultra sound probes (probe that inserted into the vagina during ultra sound procedures), were observed hanging on a rack in a public hallway. It was noted that two of the ultra sound probes were uncovered. It was noted that the tip of one of the uncovered ultra sound probes was resting against the wall surface. It was also noted that the tip of second uncovered ultra sound probe was resting against a picture frame. In addition, the tip of the third ultra sound probe was covered by a plastic sleeve containing a pale blue substance identified as ultra sound gel (a gel that conducts sound waves during the ultra sound procedure.

At the same time the Ultra Sound Technician verified that after high level disinfection the ultra sound probes were always stored hanging in the hallway.

On 7/28/11 at 9 am, the hospitals', "Environmental Facility Cleanliness" guidelines dated 2/3/09 were reviewed. It was noted that the Environmental Facility Cleanliness directed that the "Endo-vaginal probes were to be reprocessed using high level disinfection. It was also noted that instructions in the guidelines provided no direction on how to store the Endo-vaginal probes after high level disinfection.

On 7/28/11 at 9:30 am, the Ultra Sound Supervisor provided the manufacturer "Guidelines for cleaning and preparing endocavitary transducers between patients." The guidelines were reviewed and revealed, " For maximum safety one should therefore perform high-level disinfection of the probe between each patient and use a probe cover or condom as an aide to keeping the probe clean ...The transducer should be covered with a barrier. If the barrier used is a condom, these should be non-lubricated and non-medicated ... "

On 7/27/11 at 4 pm, the " Perioperative Standards and Recommended Practices, published in 2011 by the Association of perioperative Registered Nurses (AORN), was reviewed. On page 405, under Recommendation V, AORN recommended that high level disinfection items should be protected from contamination until the item is delivered to the point of use. Use of aseptic technique will protect the items from being contaminated before patient use. "