HospitalInspections.org

Based on observation, interview, and policy review, the provider failed to ensure an environment free from potential cross-contamination (spreading bacteria from one surface to another) during one of one surgical procedure. Findings include:

1. Observation on 7/21/15 from 9:30 a.m. through 11:05 a.m. of the certified registered nurse anesthetist (CRNA) A revealed:
*He had:
-Entered the operating room (OR) after putting on protective shoe covers.
-Not performed hand hygiene after putting the shoe covers on and prior to entering the OR.
-Retrieved several clean items from a medication and supply cart that were to be used during the procedure.
-Left the OR to consult with patient 34 prior to her surgical procedure.
-Returned to the OR after he had consulted with the patient and was not observed performing hand hygiene prior to re-entering the OR.
*With those soiled hands he:
-Opened several medication vials and withdrew medication from those vials into syringes.
-Had been observed administering those medications to the patient through a hub (port attached to the intravenous (IV) line to allow for medication administration) without sanitizing his hands or using gloves.
*He had not disinfected the hub prior to administering any of those medications.

Interview on 7/21/15 at 11:05 a.m. with CRNA A confirmed he had not:
*Washed or sanitized his hands after putting on the shoe covers and entering the OR.
*Washed or sanitized his hands when he re-entered the OR after consulting with the patient in her room.
*Sanitized his hands prior to administering the sedating medications to the patient.
*Disinfected the hub on the IV line prior to administering each of the different medications.
*Been able to identify why he had not used proper hand hygiene. He had stated "I would have done that at [provider name] where I also work."

Interview on 7/21/15 at 11:10 a.m. with OR registered nurse (RN) B confirmed:
*The CRNA should have:
-Washed or sanitized his hands prior to entering the OR.
-Disinfected the hub prior to administering any medications.

2. Observation on 7/21/15 from 10:20 a.m. through 11:00 a.m. of OR RN B revealed:
*Her gloves had been contaminated when she:
-Retrieved two syringes that had been placed on a window ledge.
-Opened a biohazard container (storage for hazardous [dangerous] materials) and placed both of the dirty syringes inside.
-Retrieved used and soiled items from a small garbage bag and placed them inside a different garbage bag.
*She used those soiled gloves to:
-Retrieve several clean supplies for the surgeon to use during the procedure.
-Retrieve a stretcher that was outside of the OR for the patient to be transferred to back to her room.
-Transfer the patient onto the other bed and transport the patient to another room in the building.

Interview on 7/21/15 at 11:30 a.m. with OR RN B confirmed she had created an unsanitary environment during and after the surgical procedure.

3. Observation from 10:00 a.m. through 10:55 a.m. of the surgeon revealed:
*After he performed the procedure on patient 34 he:
-Removed his soiled gloves.
-Retrieved the patient's paper chart.
-Left the OR without washing or sanitizing his hands.

Interview on 7/21/15 at 11:35 a.m. with OR RN B confirmed the surgeon should have washed or sanitized his hands after he removed his gloves. She agreed he had created the potential for cross-contamination to other patients and staff.

4. Observation on 7/21/15 from 9:30 a.m. through 11:25 a.m. of the scrub nurse C revealed:
*He had worn two pairs of gloves during the surgical procedure.
*He did not remove the top pair of gloves. With those soiled gloves he:
-Entered the decontamination room and prepared the Asepti-Zyme cleaning detergent in the sink.
-Went in and out of the OR and the decontamination room several times with soiled utensils that needed to be cleaned.
*Prior to cleaning the utensils and placing them in the ultrasonic equipment he removed the top pair of gloves.
*With the second pair of gloves he had cleaned the utensils prior to placing them in the ultrasonic equipment.
*He removed those gloves and put on a clean pair. He had not been observed sanitizing his hands between the changing of gloves.

Interview on 7/21/15 at 11:25 a.m. with scrub nurse C confirmed he should have:
*Removed his gloves after the surgical procedure, sanitized, and put on clean gloves.
*He should have removed his gloves and sanitized his hands prior to putting on clean gloves.

Interview on 7/21/15 at 11:40 a.m. with OR RN B confirmed the scrub nurse had not maintained a sanitary environment after the surgical procedure. She had stated "I trained him wrong."

5. Observation on 7/21/15 12:15 p.m. through 12:30 p.m. of housekeeper D revealed:
*She had:
-Prepared to clean the OR after the surgical procedure for patient 34.
-A large bucket of solution that she planned on using to clean the OR.
-Not been able to identify what type of disinfecting solution was in the bucket, as the solution had been premixed for her.
-Entered the the OR and further prepared to clean the room.
-Cleaned several pieces of equipment and surfaces. Some of that equipment had lower shelves underneath of them.
*Several times during the cleaning of those lower shelves her cloth had dragged across the floor.

Interview on 7/21/15 with housekeeper D at the time of the above observation revealed she had not been aware her cloth had been touching the floor while cleaning the lower shelves. She agreed that had created an unsanitary environment.

Interview on 7/21/15 at 2:50 p.m. with infection control nurse revealed:
*She had no audits or documentation to support any monitoring of the OR to ensure proper infection control processes were maintained.
*She had not been involved with the housekeeping department on the types of chemicals they used. She would have expected them to find information required to ensure effective cleaning of the facility and OR.
*She had agreed the above observations had created:
-An unclean environment for the patient.
-The potential for cross-contamination to the patient.

6. Interview on 7/22/15 at 11:10 a.m. with the director of nursing regarding the above observations and interviews further confirmed the environment for surgical patient 34 had not been maintained in a sanitary manner (clean).

Review of the provider's 2/20/14 Peripheral Intravenous Therapy policy revealed:
*"Between components [medication], the IV system will be maintained as a closed system as much as possible."
*"All entries into the tubing, as for administration of medications, will be made with sterile equipment through injection ports that are disinfected with 70 % [percent] alcohol swab."
*"Scrub the hub - 20 seconds."

Review of the provider's 9/24/13 Hand Washing and Hand Hygiene policy revealed:
*Purpose: "To establish hand hygiene as the single most important factor in preventing the transmission of disease-causing organisms to patients, personnel, and visitors."
*Responsibility: "It is the responsibility of all employees of [provider name] to wash their hands.
-Upon entering or leaving their work area.
-After touching contaminated [dirty] surfaces or items."
*"Direct caregivers and/or those employee working in clinical areas have additional responsibilities to wash their hands.
-When moving from potentially contaminated body site or environmental surface to a clean body site or environmental surface.
-Before an invasive procedure.
-Before putting on and after removing gloves."

Based on observation and interview, the provider failed to ensure one of one certified registered nurse anesthetist (CRNA) A safely administered medication obtained from an ampule (glass vial) during a surgical procedure for one of one patient (34). Findings include:

1. Observation on 7/21/15 from 9:30 a.m. through 11:10 a.m. of CRNA A during a surgical procedure for patient 34 revealed:
*He had:
-Prepared to administer medication from a glass vial.
-Retrieved an empty syringe and a regular needle.
-Opened the package containing the needle and attached it to the syringe.
-Retrieved a glass ampule from the anesthetist's medication and supply cart. Inside of the ampule was a liquid medication he would use during the sedating process.
-Opened the glass ampule by breaking it at a scored line on the ampule.
-To draw up the medication contained inside of the glass ampule using the regular needle and syringe.
-Removed the needle and administered that medication to the patient through a hub (insertion point to administer medication on an intravenous [IV] catheter) attached to her to her IV line.

Interview on 7/21/15 at 11:10 a.m. with CRNA A confirmed he:
*Had used a regular needle to obtain the medication from the glass ampule and administered it to the patient.
*Should have used a filter needle (specialized needle to remove pieces of glass) to ensure no glass particles were inside of the medication.
*Had not used a safe process when administering the medication to the patient.

Interview on 7/21/15 at 11:25 a.m. with operating room, registered nurse B confirmed CRNA A had not used a safe practice while administering a medication that was obtained from a glass ampule. She agreed he should have used a filter needle.

Interview on 7/22/15 at 11:15 a.m. with director of nursing confirmed CRNA A had not used a safe standard of practice while administering a medication obtained from an ampule.

The provider did not have a policy and procedure in place to ensure a safe standard of practice was used during the administration of a medication obtained from a glass ampule.

Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 8th Ed., St. Louis, Mo., 2013, p. 602, revealed "Preparing an Injection From an Ampule. A colored ring around the neck indicates where the ampule is prescored so you can break it easily. Carefully aspirate the medication in a syringe with a filter needle. The use of a filter needle prevents particulate matter such as small glass fragments from entering the syringe. Replace the filter needle with an appropriate-size needle or a needleless access device before administering the injection."