HospitalInspections.org

Based on review of facility documents, observation, and staff interview (EMP), it was determined the facility failed to follow industry standards for spiking intravenous (IV) bags for four of five IV bags observed, failed to ensure clean endoscopes were stored in a manner to minimize recontamination in the cystoscopy workroom, failed to ensure appropriate use of personal protective equipment, including gowns, masks, eye protection and hair coverage devices, in the cystoscopy workroom and in Operating Room One, and failed to ensure a sanitary environment in the Radiology Department.

Findings include:

1) Review on January 8, 2015, of the facility provided document from the Association of Operating Room Nurses (AORN) 2014 Edition "Standards, Recommended Practice for Medication Safety," revealed "Intravenous solution containers should be punctured as close as possible to time of use. Opened and unused medication vials, solution bags, bottles, syringes, and compounded sterile preparations should be discarded within one hour of opening. The Association for Professionals in Infection Control and Epidemiology (APIC) recommends that spiked IV solutions be used within one hour of being prepared."

Review on January 7, 2015, of the facility provided document from The Association for Professionals in Infection Control and Epidemiology (APIC) "Winter 2011/2012 Preventing Infection in Ambulatory Care" revealed "... Infection Prevention and Control Clinic Survey Tool ... 6. Safe injection practices One needle, One Syringe, One Patient, One Time ... d. IV fluids spiked at time of use Spike IV fluids and prime tubing immediately prior to use. ..."

Observation at 7:30 AM on January 6, 2015, in the anesthesia preparation area revealed two IV bags of 0.9% sodium chloride and two IV bags of lactated ringers spiked with tubing prepped for patient use. Further observation of the bags revealed January 5, 2015, 1200 as the time the bags were prepped for use. These IV bags were connected to MR14's central venous line at approximately 8:00 AM on January 6, 2015.

Interview with PF14 at 7:30 AM on January 6, 2015, confirmed the IV bags were prepped for use on January 5, 2015, at 1200. PF14 stated IV bags are prepped for the first surgical case of the morning on the afternoon the previous day. PF14 stated they were told the prepped IV bags were good for 24 hours after they were prepped for use.

Interview with EMP2 at approximately 10:30 AM on January 6, 2015, confirmed it was not the facility's policy to prep IV bags up to 24 hours in advance of their use.

2) Review on January 7, 2015, of the facility's "Testing and Use of Cidex OPA Solution for High-Level Disinfection" policy, last reviewed July 7, 2014, revealed "Policy: This document describes the procedures associated with the safe testing and use of Cidex OPA within various departments. Cidex OPA should be used in the disinfection of instrumentation designated as 'semi-critical' instruments (i.e. makes contact with mucous membranes but does not ordinarily penetrate sterile areas of the body). All steps should follow any details that are further defined by manufacture recommendations. A. Initial Cleaning 1. After use, initial cleaning of the instrument must first be performed per the manufacturer's instructions using a hospital-approved cleaning solution. 2. Rinse all instrument surfaces and lumens with large amounts of water. 3. Remove excess moisture from the instrument by drying gently. ... G. Drying and Storage 1. Dry the instrument per manufacturer instructions. 2. The disinfected instrument should either be immediately used or stored in a manner to minimize recontamination. ..."

Observation at 10:50 AM on January 6, 2015, of the cystoscopy washroom revealed hooks on the wall within three feet of the sink utilized to wash dirty endoscopes.

Interview with PF15 at 10:50 AM on January 6, 2015, confirmed the hooks on the wall were used to hang clean endoscopes to dry.

Interview on January 7, 2015, with EMP3 revealed when scopes are dry they are put into a storage cabinet in the operating room or in the cystoscopy storage area.

3) Review on January 6, 2015, of the facility's "Surgical Attire" policy, last reviewed October 21, 2014, revealed "Policy: All persons entering the area will be required to wear surgical scrub attire as provided by this facility. Street clothes are not to be worn within the restricted areas of the OR [operating room]. Procedure: ... 4. Disposable shoe covers may be worn by all persons entering the areas where predictable hazardous spills may occur. ... 7. Disposable hats or hoods that completely cover all possible head and facial hair are to be worn by all personnel entering the OR restrictive areas. ... 11. Outside the OR suite: A. Long sleeve warm-up jacket may be worn over scrub apparel. ..."

Observation in Operating Room (OR) One at approximately 9:00 AM on January 6, 2015, revealed PF16 wearing a skull cap on their head and a mask over their face and chin. An approximately two inch portion of PF16's beard was exposed on both sides of their face.

Observation in Operating Room (OR) One at approximately 9:00 AM on January 6, 2015, revealed PF10, PF14 and PF18 wearing shoes without shoe covers.

Observation at approximately 10:20 AM on January 6, 2015, revealed several male staff in the semi-restricted area wearing skull caps provided by the facility. Further observation revealed the skull caps did not provide coverage of their hair at the back of the head at the neck area.

Interview with EMP3 and EMP4 at approximately 10:20 AM on January 6, 2015, revealed male staff with facial hair were to wear a surgical hood that covered their head and facial hair. Additional interview confirmed the skull caps worn by male staff did not provide full coverage of their hair.

Interview with EMP3 and EMP4 on January 7, 2015, revealed it was an unwritten policy that OR staff may wear shoes dedicated to be worn only in the hospital without shoe covers when in the OR. EMP3 and EMP4 stated OR staff may leave the OR suite wearing the dedicated shoes anywhere in the hospital. Further interview revealed there was no facility policy delineating where the designated shoes may be worn.

4) Observation at 10:50 AM on January 6, 2015, of the cystoscopy washroom revealed face shields and waterproof gowns were not available for staff to wear when cleaning endoscopes in this area.

Interview with PF15 at 10:50 AM on January 6, 2015, confirmed face shields and waterproof gowns were not available for staff to wear when cleaning endoscopes in this area.

5) Review on January 7, 2015, of the facility document "Environment Services Duty List 3rd Floor X-Ray/Breast and Image," last revised date December 28, 2010, revealed X-Ray Rooms N3031, N3048 and N3049 to be cleaned daily.

Review on January 8, 2015 of the facility policy and procedure "Dust mopping [and] Wet mopping," last reviewed/revised on April 4, 2014, revealed "Policy: The Environmental Services Department is responsible for maintaining the cleanliness of floors throughout the facility, using products and procedures approved by the Infection Control Practitioner. ... Procedure for dust mopping: ...5. Make sure all corners are dusted well, sometimes it is useful to use the dust brush to get the dirt out of the corners. 6. Make sure you move everything that can be moved (do not dust around anything that is moveable). ..."

An observation tour of the Radiology Department was conducted on January 7, 2015 at 9:15 AM. Observation of Room N3049 revealed the corner behind the entrance door and the area between the radiology machine and wall contained tan dust and dirt particles, approximately the size of a nickel size if placed together. Room N3038 revealed the corner by the desk and wall, the area by the wall behind the computer desk, and the corner behind the entrance door contained tan dust and dirt particles, approximately the size of a nickel if placed together. Observation at 11:15 AM of Room N3031 revealed the corners and between the equipment and the wall contained tan dust and dirt particles, approximately the size of a dime if placed together.

Interview with EMP5 and EMP6 on January 7, 2015, at 9:15 AM confirmed Room N3049 and Room N3038 contained tan dust and dirt particles. Further interview at 11:15 AM in Room N3031 confirmed the room contained tan dust and dirt particles.

Interview with EMP7 on January 7, 2015, at approximately 2:45 PM confirmed X-Ray Rooms N3031, N3048 and N3049 were to be cleaned daily.