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Based on observation, interview and document review, the facility failed to maintain and provide a sanitary enviroment to avoid sources and transmission of infectious and communicable disease.

Findings:

The facility failed to thoroughly pre-clean semi-critical devices(vaginal probes), in a manner consistent with hospital policies and procedures, prior to high level disinfection.

During observation on 08/04/15 at 9:40 AM, the enzymatic cleaner (Gentingle Clean-Ready to use Rhinoenzyme Foam Spray for Manual Cleaning and Soaking), for pre-cleaning of vaginal probes, was noted to have a use-by date of 03/15. The bottle was labeled by staff "opened on 07/19/15", and was being used, although the use-by date had passed.
This finding was confirmed by two staff members at the time of the observation.

The facility does not damp dust all horizontal surfaces in the operating rooms with an Enviromental Protection Agency ( EPA) registered detergent/disinfectant prior to the first case of the day.

During interview, on 08/05/15 at 2:30 PM, two of the staff members who are responsible for disinfecting the operating room were asked what type of cleaning or disinfecting they perform prior to the first case in the morning. They stated that they do not do any type of cleaning in the morning because the terminal cleaning was completed the night before.

On 08/06/15 at 3:30 PM an operating room staff member was asked if they perform any cleaning of the operating rooms before the first case of the day and they stated they do not. The Association of Operating Room Nurses (AORN) guidelines state that "damp dusting of the operating room, with a low-linting cloth moistened with disinfectant, should be done first thing in the morning before additional items or equipment are brought into the room". The facility does not have a policy that addresses the cleaning of the operating room prior to the first case each morning.

The facility does not perform terminal cleaning of the operating rooms within acceptable standards of practice:

During observation on 08/05/15 at 3:45 PM it was noted that housekeeping staff failed to clean and disinfect wheels and casters of moveable equipment in the operating room when performing terminal cleaning.

During interview on 08/06/15 at 4:00 PM, the Infection Control Practioner (ICP) confirmed that cleaning and disinfection of wheels and casters on moving equipment in the operating room should be done as part of terminal cleaning. The facility does not have a policy for terminal cleaning of the operating room.

During observation on 08/04/15 at 10:30 AM it was noted that cardboard boxes were being stored in the clean and sterile supply area located outside the sterile processing department. The room is contiguous with the area where the operating room (OR) supply carts are sterilized. Some of the cardboard boxes were cut open and items such as sutures were being stored in the cardboard boxes.

Interview with sterile supply staff on 08/04/15 at 10:30 AM verified that this area was used as a staging area for deliveries for several departments of the hospital, including the operating room.

On 08/05/15 at 2:45 PM it was observed that a delivery of cardboard boxes had been received in the clean and sterile supply area and had been placed on top of a sterile supply cart.

The Association for Advancement of Medical Instrumentation , Standard 79, states "that clean or sterile items to be transported to central processing and storage areas within the facility should be removed from their external shipping containers before they enter the storage areas of the department".

On 08/05/15 at 7:00 AM it was observed that a RN did not properly clean the blood glucose monitoring device per the facility and manufacturer's guidelines. The RN was observed to clean the entire glucometer with an alcohol prep pad after being used to monitor a patient's blood glucose.

Review of the facility policy "Ancillary Blood Glucose Monitoring "(effective date 05/11), subsection: Infection Control, " The commercial product, Sani-Cloth Plus Germicidal Disposable Cloth has been approved for glucose meter cleaning. 70% isopropyl alcohol (alcohol prep pad) can be used to remove the film left by the germicidal wipes (to clean the charging and network connection points and the meter display) " .

Interviews with multiple day shift RNs and Laboratory staff on 08/04/15 and 08/05/15 confirmed that the policy describes the correct disinfecting procedure that is to be followed.

On 08/05/15 at 7:30 AM it was observed during a surgical case that the luer lock ports of the intravenous (IV) tubing were entered with a syringe to give medication two times on one patient and twice on another patient by the Certified Registered Nurse Anesthetist (CRNA) and the Anesthesiologist without, first, cleaning the port with alcohol.

Per the facility policy "Administration of IV push Medications to Adult Patients" (effective date 09/13) subsection: Procedures states " Prior to accessing scrub the hub for 15 seconds, clamp the tubing above the injection port and administer in the most distal port " . The policy did not include what type of cleaning agent should be used to cleanse the port prior to medication administration. Per the Centers for Disease Control (CDC) guidelines "stopcocks should be capped when not in use. Appropriate disinfectants must be used to prevent transmission of microbes through connectors. Some studies have shown that disinfection of the devices with chlorhexidine/alcohol solutions appears to be the most effective in reducing colonization. In addtion, the time spent applying the disinfectant may be important. One study found that swiping the luer activated device with 70% alcohol for only 3 to 5 seconds did not adequately disinfect the septal surface".

On 08/05/15 at 9:30 AM it was observed in the Operating Room during a surgical case that when 4 seperate medication vials were opened to be drawn up by the CRNA and the anesthesiologist, the rubber septum of the vial was not first wiped off with an alcohol prep pad prior to being punctured with a needle.

Interview with the Infection Control Practitioner on 08/05/15 at 10:00 AM confirmed that the hospital follows Center for Disease Control (CDC) guidelines for infection control practices, and the guidelines from the CDC state "the rubber septum should be disinfected with alcohol prior to piercing it". The hospital did not have a policy that stated that the rubber septum should be cleaned prior to being pierced.

On 08/05/15 at 9:30 AM it was observed in the Operating Room during a surgical case that the CRNA and the Anesthesiologist were noted to be wearing a waist pack that contained narcotics. The CRNA was observed leaving the OR with the waist pack during the procedure and then returning. The waist pack touched the head of the bed and the IV tubing when the CRNA was caring for the patient. A policy addressing the cleaning of these waist packs was not provided.

The facility failed to minimize the risk of development and the risk of transmission of multidrug-resistant organisms within the hospital.

On 08/05/15 review of the facility's "Pharmacist Managed Vancomycin and Aminoglycoside Dosing and Monitoring Protocol " indicated that pharmacy staff are involved with the monitoring of Vancomycin and Aminoglycosides, two types of antibiotics. There is no indication that a pharmacist has been designated to monitor this type of antibiotic usage. This was confirmed during interview with the facility pharmacy representative and the chief infection control officer on 08/05/15 at 10:30 AM.

A review of the facility's Infection Control Program Plan dated January 2015, on 08/05/15 noted that Focused Measures included tracking both clostridium difficile (C-diff) and Methacillin Resistant Staph Aureus (MRSA). Under the heading, "Implementation of Interventions", the policy states, " Policies are based on scientifically valid infection prevention and control measures using professional guidelines and standards such as The Association for Professionals in Infection Control and Epidemiology (APIC), Center for Disease Control (CDC),The Infectious Disease Society of America (IDSA) and the Department of Health (DOH) ".

APIC 2012 recommends the following infection prevention strategies: education of clinicians on prudent and appropriate use of antibiotics; implementation of policies aimed at prevention of infection which include prescribing e.g., guidelines and decision support involving order entry.

CDC 2015 guidelines recommend the following regarding antibiotic use: accountability when prescribing; implementation of policies and procedures to improve antibiotic use and tracking and reporting of antibiotic use and outcomes of their use. In addition to these, a core prevention strategy for the prevention of c-diff includes the implementation of an antimicrobial stewardship program.

IDSA 2012 recommends the following: processes to measure and monitor antimicrobial use at the facility for internal benchmarking; prospective surveillance and concurrent intervention for inappropriate use of antimicrobial agents; institutional guidelines for the management of common infection syndromes; and integration of clinical decision support technology into Electronic Health Records (EHRs).

The 2013 NYSDOH White Paper titled "Hospital Acquired Infections", states the following, "CDC recommends that all hospitals have antimicrobial stewardship programs."

The facility has no mechanism to ensure documentation of indications for use when medical providers order antibiotics. There is no formal mechanism to prompt re-evaluation of appropriate antibiotic usage when patients have been cultured and treated empirically; there is no vehicle to track and trend antibiotic usage in conjunction with cases of c-diff and multi-drug resistant organisms; there is no oversight of antimicrobial usage. These findings were confirmed during interview with the facility pharmacy representative and the chief infection control officer on 08/04/15 at 10:30 AM.

On 08/04/15 at 11:00 AM a review of the facility policy titled "Infection Control Guidelines for Transmissible Spongiform Encephalopathies" [group of progressive conditions that effect the brain and nervous system e.g. Creutzfeldt-Jakob disease (CJD)] was performed. The policy states that admitting physicians or registered nurses are to notify the Infection Control Department when a potential or known patient with CJD is admitted to the hospital, or any patient who meets the criteria ...

The Infection Control Department is not aware of the presence of patients suspected of having spongiform encephalopathies. On 08/05/15 at 2:00 PM, the chief infection control officer and the infection control nurse stated that they had no knowledge of brain biopsies being performed in the facility to rule out CJD. On 08/05/15 at 7:00 AM, the nurse manager of the operating room stated that a fair number of biopsies had been performed at the facility to rule out CJD.