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Based on generator log review and interview it was determined the facility did not meet Life Safety Code requirements related to monthly load testing of the generator. The failed practice had the potential to affect all patients, staff and visitors. The facility had a census of 8 patients on 11/05/13. See Tag K-144.

Based on observation, interview, review of manufacturer's guidelines, and policy and procedure, it was determined the facility failed to follow manufacturer's directions for use of the disinfectant solution; failed to use a disinfectant approved by the Infection Control Committee; and failed to assure policies and procedures were current. It could not be assured disinfection of respiratory therapy equipment occurred and infection would be prevented. The failed practice was likely to affect any patient admitted to the facility who received respiratory care. The findings were:

A. Observation on 11/06/13 from 0900-0930 revealed liquid in a large covered container. The container and liquid were identified by the Respiratory Therapy Supervisor as the disinfectant in which respiratory equipment was soaked. In an interview, the Respiratory Therapy Supervisor stated on 11/06/13 at 0930 the solution in the container was prepared by adding one ounce of Control III per one gallon of water. The Respiratory Therapy Supervisor stated, once prepared, the solution was used for 30 days, then discarded and a new solution prepared. The container with solution was not labeled with any identifying information; the contents, dilution, date of preparation or date of expiration. The items that were surface cleaned (IPPB machine, compressors, flow meters, oxygen analyzers, etc ...) and could not be submerged were sprayed with Control III Elite disinfectant.
B. The manufacturer's product insert for Control III was reviewed on 11/06/13 at 0930 and revealed the following:
1) "Control III disinfectant germicide has not been tested for effectiveness against Mycobacterium tuberculosis and must not be relied upon when a tuberculocidal product is desired."
2) Place prepared disinfectant germicide solution in a plastic container. The re-use container must be labeled with the product name, signal word, preparation date (mm/dd/yy) and expiration date (mm/dd/yy).
3) "The solution may be reused for up to 14 days."
4) "If the solution becomes visibly dirty or falls below 1000 ppm (parts per million) discard the used solution and make a fresh solution."
C. The Respiratory Therapy Supervisor was questioned at the time of interview on 11/06/13 at 0930 how they assured the Control III solution strength was maintained above 1000 ppm (parts per million) as required by product labeling. She replied "we change it every 30 days. We have never tested it."
D. On 11/06/13 at 1245 and 11/07/13 from 1335-1420, the Infection Preventionist was interviewed. The Infection Control Committee Meeting Minutes and Infection Control policies were reviewed. The Infection Preventionist confirmed at the time of the interview that neither the Control III (used for submerging items) nor the Control III Elite (surface spray) disinfectant identified by the Respiratory Therapy Supervisor were on the list of disinfectant products reviewed and approved to be used in the facility by the Infection Control Committee.
E. The Respiratory Therapy Policy and Procedure Manual was reviewed on 11/05/13 and 11/06/13. The policies and procedures provided on initial review were not reflective of the manufacturer's directions for use and were not reflective in the use of approved disinfectants.
1) The first page of the policy and procedure manual was signed as reviewed on 06/17/13 by the Respiratory Therapy Supervisor and the Chief Executive Officer, and on 06/19/13 by the Medical Director.
2) The policy "Infection Control," reference #2.6.6.1, revised 08/17/2009 stated: Equipment processing "The following steps should be taken to ensure appropriate processing of each piece of equipment: (Ventilator filters, reusable inhalation and exhalation, etc...)-package and send to Central service for sterilization. Rubber t-piece and collection bottle will be cleaned in soap and water then placed in Control 3 disinfectant (Germicide) for 15 minutes."
3) The policy and procedure manual provided on initial review did not include:
a) A policy that specified the Control III product used for submerging equipment was to follow the manufacturer's directions for the disinfection/germicide preparation, labeling, or use of the Control III product.
b) There was no policy to assure the prepared Control III disinfectant used for submerging equipment did not fall below 1000 ppm or to discard solution if visibly dirty.
c) There was not a policy that described the use of the Control III Elite product for spray surface disinfection of equipment that was not submerged.
4) The findings were confirmed by the Respiratory Therapy Supervisor on 11/06/13 at 0930.
F. The Respiratory Therapy Supervisor presented additional policies on 11/07/13 at 1005 for "Chemical Disinfection", "Decontamination of Equipment and Control of infection." The policies had an update of was 06/28/04, and 1991. She stated she found the policies "in the Policy Book behind another policy. These were the ones we had before they revised the policies." This Chemical Disinfection policy stated "The chemical currently in use for disinfecting equipment is Control III Elite a Double/Quat." The Respiratory Therapy Supervisor confirmed at the time the policies were presented that Control III, not Control III Elite, was the product that was used to soak equipment as identified at the time of survey.

Based on clinical record review and interview, it was determined the facility failed to have orders for two (#1 and #2 ) of three (#1-#3) patients admitted to Swing-Bed status. Without a physician's order for admission, the facility could not assure services furnished would meet the patients medical needs from acute care to swing-bed status. The failed practice affected Patient #1 and #2, and was likely to affect any patient admitted to swing-bed status.

A. A list of patients in Swing-Bed status was requested and received on 11/05/13. Patient #1 was identified by the Swing-Bed Coordinator as being admitted to Swing-Bed status on 11/01/13 at 1435. Patient #1 was received from an outside acute care facility. Clinical record review was performed on 11/08/13. Physician orders from 11/01/13 to 11/08/13 were reviewed with no order to admit the patient to Swing-Bed status was noted.
B. Patient #2 was identified by the Swing-Bed Coordinator as being admitted to swing-bed status on 11/04/13. Clinical record review was performed on 11/08/13. Physician orders from 11/04/13 to 11/08/13 were reviewed and no order to admit the patient to swing-bed status was noted.
C. The Swing-Bed Coordinator confirmed the findings on 11/08/13 at 1100.