HospitalInspections.org

Based on observation, staff interviews and review of facility policies related to pharmacy, respiratory therapy and infection control policies and procedures the facility failed to ensure the facility had incorporated measures to prevent and control infection and communicable disease when:

- Observation of the anesthesia cart in Operating Room 10 found a multidose vial that had been used for Patient 1 and returned to the anesthesia cart in the immediate patient care area.
- Patient care provided by staff for 2 of 2 sampled ventilator patients (Patient 8 and 10) revealed staff failed to adequately clean aerosol nebulizer cups after use and failed to change gloves after contamination when providing care to Patient 8.

The total sample size of 12 was selected from a facility census of 148.

Findings are:

A. Observation in Operating Room (OR) 10 on 7/24/12 from 12:30 PM until 2:45 PM revealed a combination locked anesthesia cart next to the anesthesia machine. Certified Registered Nurse Anesthetist (CRNA) B drew up and labeled Fentanyl, Versed, Propofol, Decadron, and Zofran on a surgical towel placed on top of the anesthesia cart prior to administration to surgical patient 1. The CRNA reported Succinocholine was administered to Patient 1 just prior to intubation during observation of the surgery. After the surgical procedure ended the Director of Surgical Services was asked to open the anesthesia cart. Inside the locked cart was a multi dose vial of Succinocholine that had been opened and used on another patient or patients. The vial had a hand written expiration date of 8/22/12. There were no other multi use vials of medication in the cart.
Staff interview with CRNA B on 7/24/12 at 2:40 PM revealed single use vials are thrown out after use. CRNA B confirmed multi dose vials such as "Decadron and Neo Synephrine multi dose are used for more than one patient."
Record review of facility policy titled "Safe Injection Practices" effective date 3/1/12 direct staff that multi dose "vials are stored away from the immediate patient treatment area." The faciliy failed to implement safe injection practice to prevent the spread of infection/communicable disease by having multi dose vials of injectable medication kept in an anesthesia cart in the OR, a immediate patient treatment area.

B. Observation of patient care provided to Patient 8 on 7/23/12 from 1 PM until 1:40 PM revealed Registered Respiratory Therapist (RRT) C used the alcohol based foam hand wash in the patient's room and donned gloves. The RRT then typed information on the computer keyboard at the patient bedside and proceeded to instill Xopenex, a respiratory medication, and saline into a nebulizer cup and connect it to the patient's ventilator tubing for an aerosol nebulizer treatment. After the respiratory treatment the RRT removed the nebulizer plastic cup, took it by the sink and wiped it out with a paper towel. RRT C then placed the cup upside down on a clean paper towel by the sink in the patient's room. The RRT removed the gloves and used the alcohol foam before leaving the room.
Interview with Infection Control Preventionist Registered Nurse D immediately after the observation ended on 7/23/12 at 1:40 PM confirmed the RRT did not change gloves during the observation. Additional interview with RN D on 7/25/12 at 12:40 PM related it is facility policy to consider the computer keyboard contaminated and related the observation of RRT C who gloved, touched the keyboard then prepared and gave an aerosol treatment "was not in compliance with facility policy."
Record review of the facility Infection Prevention Policy titled "Environmental Cleaning & Disinfection " last reviewed 2/2012 revealed the policy states "Computer keyboards should be considered contaminated." Review of facility policy titled "Hand Hygiene and Surgical Scrubs" with a last revised date of 2/12 states "Hands are decontaminated after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient." The purpose of the implementation of the policy is "to reduce the risk of spreading nosocomial infections via hands."

C. Observation on 7/23/12 from 1 PM until 1:40 PM included the cleaning of the nebulizer cup after an aerosol treatment for Patient 1. RRT C was observed to wipe the cup out with a paper towel and place it upside down on a clean paper towel by the sink in the patients room.
Observation of Patient 10 on 7/23/12 from 3:05 PM until 3:40 PM revealed RRT E gave the patient a aerosol nebulizer treatment. After the treatment RRT E took the nebulizer cup to the sink and shook out any remaining liquid. RRT E then placed the nebulizer cup in the clear plastic drawstring bag near the Oxygen meter.
Record review of Respiratory Care policy titled "Aerosol Therapy via Small Volume Nebulizer" with a last revised date of 10/20/10 under section titled "Infection Control" states staff are to "Disassemble nebulizer; discard excess medication in a sink with running water. Store disassembled nebulizer in a plastic bag between uses."
The facility failed to ensure the CMS requirement to rinse the nebulizer cup with sterile water (or with tap water followed by isopropyl alcohol) and dried thoroughly between uses on the same patient was implemented as a best practice to prevent healthcare acquired infections.