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Based on observation, interview, and record review the facility failed to ensure that the policies and procedures for flash sterilization are followed as evidenced by failure to consistently include or identify the name/items that were flashed sterilized in 3 out of 4 flash sterilizers Autoclave Log Books in the operating suite.
The findings include:
Observation on 10/30/2012 at 10:00am of the operating room department revealed the facility has 4 flash sterilizers. Each of the flash sterilizers had a binder, titled" Autoclave Log Book." Observation of the 4 Autoclave Log Books ' revealed daily printouts from each use/run of the flash sterilizers, as well as patient identifiers. However, there was no evidence of documentation of what items/surgical instrumentation were actually flashed sterilized for each patient from the printouts of each autoclave use/run. These findings were evident in 3 out of 4 of the flash sterilizers in the operating room suite. According to the documentation in the Autoclave Log Books, this lack of complete documentation of the actual items/surgical instrumentation did not exist for 3 (Autoclaves #5, #6, and #8) out of the 4 autoclaves. The missing data was evident for multiple days during the month of October 2012.
Interview on 10/30/2012 at 10:29am with the Director of Surgical Services confirmed the above findings. She revealed that the policy of the facility is to document each surgical instrument that is flashed sterilized in the facility.
Review of the facility policy and procedure titled, " Flash Sterilization Methods " revealed, in the procedures section; 14) Place sterilizer indicator used in an Autoclave Log Book. The patient ' s specimen label is used to log the process. Date, time in and time out, and items sterilized should be noted.

Based on observation, interview, and record review the facility failed to ensure that the policies and procedures for flash sterilization are followed as evidenced by failure to consistently include or identify the name/items that were flashed sterilized in 3 out of 4 flash sterilizers Autoclave Log Books in the operating suite.
The findings include:
Observation on 10/30/2012 at 10:00am of the operating room department revealed the facility has 4 flash sterilizers. Each of the flash sterilizers had a binder, titled" Autoclave Log Book." Observation of the 4 Autoclave Log Books ' revealed daily printouts from each use/run of the flash sterilizers, as well as patient identifiers. However, there was no evidence of documentation of what items/surgical instrumentation were actually flashed sterilized for each patient from the printouts of each autoclave use/run. These findings were evident in 3 out of 4 of the flash sterilizers in the operating room suite. According to the documentation in the Autoclave Log Books, this lack of complete documentation of the actual items/surgical instrumentation did not exist for 3 (Autoclaves #5, #6, and #8) out of the 4 autoclaves. The missing data was evident for multiple days during the month of October 2012.
Interview on 10/30/2012 at 10:29am with the Director of Surgical Services confirmed the above findings. She revealed that the policy of the facility is to document each surgical instrument that is flashed sterilized in the facility.
Review of the facility policy and procedure titled, " Flash Sterilization Methods " revealed, in the procedures section; 14) Place sterilizer indicator used in an Autoclave Log Book. The patient ' s specimen label is used to log the process. Date, time in and time out, and items sterilized should be noted.