HospitalInspections.org

On the days of the Complaint Survey based on observation(s), interview(s) and hospital policy and procedure review, the hospital failed to ensure that staff in the Endoscopy Suite performed hand hygiene per the hospital's own policy and procedures for 1 of 1 Registered Nurses (Registered Nurse #1) and 1 of 1 Surgical Technicians (#1).


The findings are:


Random observations in the Endoscopy Suite on 8/14/2012 at 0945 post endoscopy procedure showed Registered Nurse #1 failed to wash or sanitize his/her hands while transferring the dirty scope from the endoscopy procedure room to the cleaning room. Although gloves were worn and changed, Registered Nurse #1 failed to perform any hand hygiene pre cleaning, during the cleaning process, and/or after the procedure prior to disinfection of the scope. The finding was verified with the Endoscopy Director on 8/14/2012 at 1030 and with the Infection Control Officer on 8/15/2012 at 1055.

Random observations in the Endoscopy Suite on 8/14/2012 at 1000 post endoscopy procedure showed Surgical Technician #1 failed to wash or sanitize his/her hands while transferring the dirty scope from the endoscopy procedure room to the cleaning room. Although gloves were worn and changed, Surgical Technician #1 failed to perform any hand hygiene before scope cleaning, during scope cleaning , and/or after the completion of the procedure prior to disinfection of the scope. The finding was verified with the Endoscopy Director on 8/14/2012 at 1030 and with the Infection Control Officer on 8/15/2012 at 1055.

Hospital policy and procedure, Standard Precautions-Infection Control:, reads, "...Gloves: Healthcare Workers will: Wear gloves (clean and non-sterile gloves are adequate) when touching blood, body fluids, secretions and contaminated items. Put on clean gloves just before touching mucous membranes and non-intact skin. Change gloves between tasks and procedures on the same patient after contact with material that may contain a high concentration of microorganisms. Remove gloves promptly after use, before touching non-contaminated items and environmental surfaces and before going to another patient, and wash hands immediately to avoid transfer of microorganisms to other patients or environment..." .

On the days of the Complaint Survey based on random observation(s), interview(s), and review of hospital policy and procedure, the hospital failed to ensure that the patient environment and supplies were cleaned and sanitized per its own policy for 1 of 1 Registered Nurse observed using a Glucometer (Registered Nurse #2), and soiled and clean linen on the floor, and failure to rinse and air dry a nebulizer post treatment by Respiratory Therapist #1.


The findings are:


Random observations on 8/13/2012 at 1545 in the Intensive Care Unit revealed Registered Nurse #2 obtained the Glucometer from its station in the Nurse Station, transported the Glucometer into a patient's room, obtained the glucose reading, and then transported the Glucometer back to the nurse station to the base without cleaning the Glucometer. When asked why the Glucometer was not cleaned after use on a patient, Registered Nurse #2 reported that the Glucometer should have been cleaned using a Cavi-wipe, but none were readily available at the moment.

Hospital Policy and Procedure, LAB-POC-BS-09.01 Bedside Glucose-Accu-check for Nursing-PRO, states, "...MAINTENANCE: Proper cleaning of the Accu-Check Inform CMC?Hospital Meter important to keep it in good working condition and is essential for accurate results as well as for infection control measures. Meter is inspected monthly and cleaned by taking an alcohol wiper, (rung out well) and wiping...".




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On 8/13/12 from 1540 to 1555, random observations of the soiled linen room and clean linen room revealed soiled linen piled in laundry bags on the floor in the walkway and an industrial fan covered by blankets. Random observations of the clean linen room revealed folded clean gowns and wash cloths on the floor by the linen carts. The findings were verified by the Infection Control Nurse and Director of Quality on 8/13/12 at 1555.

On 8/13/12 at 1620, random observation(s) of the surgical unit hallway revealed Operating Room Staff Member #2 entering an elevator with a surgical mask around his/her neck. The findings were verified by Infection Control Nurse on 8/14/12 at 1400.

On 8/14/12 from 1120 to 1128, random observations of a patient receiving an Albuterol and Atrovent inhaler via Hand-Held Nebulizer revealed post patient usage, Registered Respiratory Therapist #1 failed to rinse and air dry the nebulizer. The findings were verified by Director of Quality on 8/14/12 at 1600.

Hospital Policy, "Revision 8/27/2010, "Hand Held Nebulizer, reads, "Procedure. #18. Disassemble device and rinse the mouthpiece and nebulizer cup with water and dry....".