HospitalInspections.org

- The CAH 's policy titled, " Hand Washing and Hand Hygiene " , reviewed on 11/30/11 at 10:45am directed, " ...Alcohol based hand sanitizers, indications for use ...before donning gloves ...after removing gloves ... "

- Review of the manufacturer 's guidelines for the use of the Virex 256 One-Step disinfectant cleaner on 11/29/11 at 2:00pm stated, " ...To disinfect hard, porous surfaces, treated surfaces must remain wet for 10 minutes ... "

- Review on 11/30/11 at 10:15am of information provided by the CAH regarding the cleaner " Crew " used to clean the inside of the toilet bowl revealed " Crew " is a bathroom cleaner and scale remover.

Staff D administrative staff interviewed on 11/30/11 at 10:15 acknowledged the cleaner "Crew " does not contain a disinfectant.

- Observation on 11/29/11 between 1:00pm to 2:00pm staff B cleaned room 260, a discharged patient 's room. Observations revealed the following breaches in infection control practices regarding hand hygiene, disinfectant wet time per manufacturer 's recommendation, and cleaning room dirty areas to less dirty areas. For example:

Staff B wearing gloves, sprayed Virex 256 solution on the pillows, mattress, over bed tables, sink, toilet seat, shower curtain, and shower walls. Staff B returned to the cleaning cart in the hallway retrieved a dry cloth, returned to the bath room, wiped the sink, toilet seat, shower curtain, walls of the shower, seat of the stool riser, and base of the toilet stool using the same cloth. The surfaces failed to remain wet for 10 minutes required for disinfection. Staff B returned to the cleaning cart retrieved a bucket of " Crew " solution and toilet bowl swab, returned to the bath room, swabbed the inside of the toilet, and stool riser then returned to the cleaning cart in the hallway. Staff B retrieved the glass cleaner form the cart, returned to the bath room and cleaned the mirror. Staff B retrieved a wipe to clean stainless steel, returned to the bathroom and wiped the stainless steel fixtures in the bath room.

Staff B returned to the cleaning cart in the hallway, wearing the same gloves retrieved a spray bottle that contained Virex 256 and a dry cloth. Staff B returned to the room sprayed a lounge chair, waste basket, bedside table, and drawers of the bedside table. Staff B wiped off each item with the dry cloth immediately after spraying them with the Virex 256 solution. The surfaces failed to remain wet for 10 minutes required for disinfection. Staff B returned to the cleaning cart in the hallway removed their gloves, filled out a work order for maintenance and applied clean gloves. Staff B returned to the room, using the spray bottle of Virex 256 and a dry cloth sprayed and wiped the bed frame, mattress, pillows, over bed tables, and window sills. Staff B returned to the cleaning cart in the hallway and placed the Virex 256 spray bottle back in the cart. Staff B wearing the same gloves walked to linen closet and obtained clean linen to make the bed. Staff B removed their gloves on the way back to the patient 's room and placed them in the trash bag on the cleaning cart. Staff B entered the room and made the bed with the clean linen.

Staff B wearing gloves took a microfiber pad out of the " Stride " solution (a solution used to clean the floors), placed the wet pad on the floor in the room and attached the handle to the microfiber pad. Staff B removed their gloves, and mopped the floor in the patient 's room. Staff B applied gloves, swept up the dirt from the floor and removed their gloves.

Staff B failed to perform hand hygiene three times when they removed and reapplied their gloves. Staff B failed to remove their gloves when they retrieved the clean bed linen from the linen closet.

Staff B interviewed on 11/29/11 at 2:00pm acknowledged the surfaces need to remain wet for 10 minutes to achieve disinfection. Staff B failed to be aware of the need to perform hand hygiene after removing gloves and/or before applying gloves.









25604

The Critical Access Hospital (CAH) reported a census of ten patients. Based on observation, staff interview, and policy review the infection control officer failed to develop an active infection control system to identify, report, investigate, monitor, and implement infection control practices for two of four observations of staff using patient care equipment and one of one observation of staff cleaning a discharged patient's room.

Findings include:

- The CAH's Infection Prevention Plan reviewed on 11/30/11 at 8:40am directed "...The Infection Prevention Program will identify and reduce the risks of acquiring and transmitting infections among and between patients, Associates, medical staff, contracted service workers, volunteers, students and visitors..."

Staff E interviewed on 11/30/11 at 9:05am verified they were responsible for the management of the infection control program. Staff E acknowledged they did not have a formal surveillance program with criteria for staff and environmental practices observing breaches in infection control.

- The CAH's policy "Cleaning of Equipment" reviewed on 11/29/11 at 9:30am directed "...ensure that all equipment is being properly cleaned before and after patient use ..."

- Observations during the survey process revealed the following breaches in infection control practices regarding cleaning of patient care equipment.

Nursing staff C observed on 11/28/11 at 1:00pm entered patient #16's room obtained vital signs using a vital sign machine and blood pressure cuff. Staff C left patient #16's room, when to patient #19's room and obtained vital signs using the same vital sign machine and blood pressure cuff. Staff C left patient #19's room and placed the vital sign machine in room 204. Staff C failed to clean the vital sign machine or blood pressure cuff between patients.