HospitalInspections.org

Based on document review and staff interview, the facility does not ensure that documentation is maintained for the cold sterilant, Metricide, including the efficacy testing at the time of reprocessing.

Findings include:

Interview with Staff #62, Assistant Director of Surgical Services, on 11/22/13 at 11:00 AM revealed that the facility does not document when the Metricide solution is changed. In addition, it was noted that staff performing reprocessing of the endoscopes are to document, on the printed tape generated from the Custom Ultrasonic 83 Plus Unit, if the efficacy of the activated Metricide solution is of adequate concentration.

Review of the manufacturer recommendations on 11/22/13 at 1:30 PM indicated that the solution must be changed every 14 days and that the glutaraldehyde concentration must be verified before each cycle to detect unexpected dilution.

Review of the facility document, Steps to Cleaning Scopes when Patient and Scope Information is Already Entered in Computer, indicates that the "Cidex" is to be tested and recorded as a pass or fail.

Review of the printed tapes for the endoscopic reprocessing unit does not consistently indicate that the Metricide was tested with each scope that was reprocessed. Review of these tapes revealed the following:

-In October 2013, the efficacy of the Metricide was not with each scope on the 8, 9, 11, 15, 16, two scopes on 10/25, 29 and 30/13.

-In November 2013, the efficacy of the Metricide was not documented with each scope on the 4, 5, 7, 12; three scopes on 11/13/13 and 11/14/13 and two scopes on 11/15/13.

Phone interview with Staff #62 and Staff #5, Risk Management System Coordinator, on 12/11/13 indicated that the efficacy of the activated Metricide solution had been performed on the above noted dates but staff had not documented the result on the printout.

Based on observation, interview, policy and procedure review and document review, the hospital does not have an established process to ensure the automated external defibrillator (AED) in the emergency department (ED) is maintained ready for use.

Findings include:

Observation during tour of the ED on 11/18/13 at 11:50 AM with Supervisor of Performance Management Staff #3 revealed there was a Philips HeartStart FRx AED located on the wall next to a code cart (which contained equipment and medications for use during resuscitation). ED Nurse Manager Staff #8 stated the AED is kept for use in a situation when resuscitation was needed outside of the hospital on the campus. When asked when the AED and the code cart were checked for readiness for use, Staff #8 stated that the code cart was checked daily by ED nursing staff and the AED was checked by facility biomed staff once per year. He stated that ED staff do not check the AED readiness light on a periodic basis. Upon opening the AED case, it was noted the date of inspection was 2/13, with due date of 2/14. The AED pads had an expiration date of 4/13.

Review on 11/19/13 of policy #NS.340 "Code Team" (issued 12/12, revised 11/13) revealed the policy addressed the multi-phasic defibrillators located on top of the code carts in the hospital, but not the AED. The policy stated the Code Cart shall be inspected once every 24 hours when a clinical area is open for patient care, with documentation on the Code Cart and Defibrillator Checklist Form. The first expiration date of an item in the cart is recorded. Central Service shall place all code carts on a cycle for inspection based on the expiration date and replace the cart prior to the last day of the month of expiration. Review of the Code Cart Inventory List revealed the multi-phasic defibrillator and pads located on top of the cart are checked daily; there was no documentation on the daily checklist in use regarding the AED. The policy did not address the AED, including periodic checks for readiness or a process to ensure supplies and accessories are not expired.

Further observation at that time revealed there was no manufacturer's instructions for use manual located by the AED. It was requested from and provided by facility staff on 11/19/13. Review of the "HeartStart FRx Defibrillator" owner's manual, edition 11, dated 2013, revealed the provided maintenance tag should be used to record the expiration of the attached pads and the maintenance tag and maintenance booklet should be kept with the AED. It is required to periodically check the green Ready light, replace any used, damaged or expired supplies and accessories, and check the outside for damage. The booklet stated: "As long as a battery and a pads set are installed, the green Ready light should be blinking to show that the FRx has passed its most recent (daily) self-test and is therefore ready to use." However, hospital staff do not check the readiness light more frequently than once per year.