HospitalInspections.org

Based on observation, interview and record review the facility failed to ensure the staff were competent with infection control processes's that include sterilizing patient equipment and demonstrating the correct procedure to clean instruments and storing supplies.

Findings Include:

Observation on 06/18/2019 at 1110 in sterile processing revealed the central sterile technician (CST) ID #59 could not verbalize or demonstrate the correct process to soak instruments prior to sterilization.

Interview on 06/18/2019 at 1110 with the Central Supply Manager, ID # staff 58 who stated, she [staff #59 CST] should know better, the water level should be at the line.

Interview on 06/20/2019 at 1134 with Manager of Endoscopy ID # staff 74 who stated, we don't have competencies for the techs cleaning the scopes but we're going to implement them. We have general competencies only.

Record review of the facility policy "Cleaning and Disinfection" dated 05/2013 stated:
Patient Care Equipment
A. The level of disinfection or sterilization of patient care items and equipment will be based on the type of device, how it is used, and the manufacturer's recommendations.
1. Critical items: Devices that enter sterile tissue or the vascular system (e.g. surgical instruments ... ) will be sterilized.

Observation of 06/18/2019 at 1020 revealed a dirty janitors closet in the operating room, with dirty items on the floor, ceiling tiles open on the ceiling and open wall covered with plastic paper of exposed pipes.

Interview on 06/18/2019 at 10290, with the ID # 64, who stated a work order has been created to address the open areas in the closet. He acknowledged the janitors closet was dirty and needed cleaning.

Record review of facility policy Infection Control Guidelines for Surgery dated 1/2017 stated, housekeeping in the Operating room, keep the facility neat, clean and safe.

Observation on 06/18/2019 at 1130 of the stock room, revealed boxes of sterile and unsterile supplies on the floor in the stock room.

Interview with the Director of Surgical Services, ID # 55 at the time of observation stated "boxes should not be on the floor".

Record review of the facility policy "Sterility of Equipment and Supplies" dated 07/2014 stated;
Sterile Equipment and Supplies
A. Storage
1. Sterile items will not be stored on the floor.
2. Sterile items will be stored on clean shelving above storage of non-sterile items.
3. Sterile supplies will not be stored in areas where the potential for water damage is great (i.e., near sinks, eye wash stations, etc.).