HospitalInspections.org

The hospital reported a census of three patients. Based on observation, staff interview, and lack of policy the hospital failed to ensure expired single use sterile items were disposed of appropriately in one of one Malignant Hyperthermia cart. This deficient practice had the potential for improper use of supplies.

- Malignant Hyperthermia Cart in the Operative corridor area observed on 1/25/2016 at 12:00 PM revealed the following expired supplies:
1) Three surgical sterile glove packages sizes 6 ½, 7 ½, and 8 with expired dates of 9/2014 and 8/2015.

Staff A interviewed on 1/25/2016 at 12:05 PM acknowledged the expired patient supplies should have been disposed and replaced.

- Policy reviewed on 1/26/2016 at 4:30 PM the hospital failed to have a policy on expired supplies.

The Hospital reported a census of three patients. Based on observation, policy reviews and staff interviews the infection control officer failed to ensure hand hygiene was performed properly for four observed hand hygiene opportunities, and failed to ensure proper PPE (personal protective equipment)(items worn to provide a protective barrier from potentially infectious material)was worn in the OR (Operating Room) for one of two surgeons observed, failed to ensure proper PPE was immediately available for use at two of two hoppers (flushable sink used to dispose of liquid waste), failed to ensure the required dwell time (time required for cleaning product to disinfect the surface being cleaned) was observed in one of one discharged patient room cleaning, and failed to ensure ten of ten stools located in the OR had cleanable surfaces. This deficient practice has the potential to expose all patients and healthcare workers to infectious diseases.


Findings include:

- Preoperative unit observed on 1/25/2016 at 10:25 AM revealed RN Staff C did not perform hand hygiene when entering patient room #3 to provide patient care.

RN Staff C interviewed on 1/25/2016 at 10:30 AM acknowledged they did not perform hand hygiene when entering the patient ' s room.

- Preoperative unit observed on 1/25/2016 at 10:40 AM revealed RN Staff D did not perform hand hygiene when leaving patient's room #1 after inserting an IV (intravenous )(device used to access a blood vessel for the purpose of delivering medications or fluids into the body) and removing her gloves.

RN Staff D interviewed on 1/25/2016 at 10:43 AM acknowledged they did not perform hand hygiene after leaving the patient's room.

- Inpatient unit observed on 1/26/2016 at 8:12 AM revealed RN Staff F did not perform hand hygiene when entering patient room 203 to provide medications.

RN Staff F interviewed on 1/26/2016 at 8:12 AM indicated they did perform hand hygiene before entering patient's room 203.

-Observation of cleaning of a discharged patient's room on 1/26/16 between 1:55pm to 2:53pm revealed staff G (housekeeper) failed to perform hand hygiene three times when removing and reapplying gloves.

Administrative staff A interviewed on 1/26/16 at 1:55pm acknowledged and observed Staff G remove gloves and reapply gloves without performing hand hygiene. Staff A acknowledged staff G failed to follow the manufacturer's guidelines when cleaning the toilet.

Policy titled "Hand Hygiene" reviewed on 1/26/2016 at 3:30 PM directed "...All Clinical Hospital Employees will perform hand hygiene practices at least; prior to and after any direct contact with patients and after removing gloves ..."

- Surgeon Staff H observed on 1/25/2016 at 1:00 PM in OR # 4 revealed Staff H wearing a skull cap with hair exposed at the nape of their neck.

Administrative Staff A interviewed on 1/25/16 at 3:30 PM acknowledged surgical staff should wear a head covering that covers all their hair and skull caps should not be worn unless covered by a bouffant.

Policy titled "Attire in the Operating Room" reviewed on 1/26/2016 at 8:15 AM directed "... All possible head and facial hair including sideburns, beards and neckline should be covered when in the semi restricted and restricted areas of the surgical suite ..."

- AORN 2012 Recommendation IV reads: "All personnel should cover their head and facial hair when in the semi-restricted and restricted areas. Hair coverings should cover facial hair, sideburns and the nape of the neck ...Skulls caps are not recommended because they do not completely cover the wearer's hair and skin: they fail to cover the side hair above and in front of the ears and the hair at the nape of the neck.

- Observation of cleaning of a discharged patient's room on 1/26/16 between 1:55pm to 2:53pm revealed staff G (housekeeper) cleaning the toilet bowl inside and out. Staff G, using a swab mop wet with a solution of QT-TB disinfectant swabbed the inside of the toilet and then immediately flushed the toilet. Staff G sprayed the outside of the toilet with a solution of the QT-TB disinfectant and immediately wiped it off with a cloth.

- The manufacturer's guidelines for the QT-TB disinfectant reviewed on 1/26/16 at 3:25pm directed "...Spray area until it is covered with the solution. Allow product to penetrate and remain wet for 3 minutes ...disinfection of toilet bowls and urinals: Remove water from bowl ...apply 1 to 2 ounces of this product evenly, allowing sufficient time for product to cover entire surface of bowl for maximum cleaning. Swab bowl completely ...let stand 3 minutes"