HospitalInspections.org

Based on manufacturer's recommendations, policies/ procedures, hospital documents, staff interviews and observations, it was determined that the facility failed to provide a sanitary environment to avoid sources and transmission of infections as evidenced by:

1. failure to follow directions for use for disinfection of non-porous surfaces according to manufacturer's recommendations;

2. failure to disinfect transportation equipment after patient use and prior to leaving the area; and

3. failure to follow hand hygiene protocols per hospital policy and hospital teachings.

This citation does NOT raise to a CONDITION level.

Findings include:

1. Virex 256 DIRECTION FOR USE requires: "...to disinfect hard, non-porous surfaces, treated surfaces must remain wet for 10 minutes...."

Environmental Services Aide job description requires: "...Maintains working knowledge of cleaning chemicals to ensure proper dilutions and establish usage..."

Observations made on the Multi-organized Service Unit (MOSU) on 12/03/14 at 1030 hours noted that Employee #24, applying the disinfectant (Virex 256) to a bed and wiping/drying the bed off almost immediately, leaving little or no contact time as required by the manufacturer.

Employee #24 confirmed during an interview conducted during the observation that she applied the disinfectant and wiped it off immediately because the nursing staff told her the room "turn over" was needed to be completed quickly.

The Supervisor of Environmental Services confirmed during an interview conducted on 12/03/14 at 1300 hours, that the manufacturer of Virex 256 requires the surface of the bed to remain wet with the disinfectant for a minimum of 10 minutes.

2. Clinical Nursing Skills Basic to Advanced Skills, 8th Edition, Chapter 14, Page 442, requires: "...Instruct all hospital personnel to complete hand hygiene before they leave the area...wipe down transportation vehicle with an antimicrobial solution...."

The Director of Quality and Risk Management confirmed during an interview conducted on 12/03/14 that the hospital uses "Clinical Nursing Skills Basic to Advanced Skills" as the hospitals nursing reference.

During the same observation on the MOSU unit, it was noted the Radiology Transporter after taking the patient to his room, stopped to talk with staff at the nurses station; removed her gloves without washing or using gel on her hands; and left the patient area without disinfecting the wheelchair prior to leaving the floor.

The Transporter was questioned regarding her hand hygiene and responded that the gel makes her hands dry and she would wash her hands when she returned to radiology.

3. Hospital Hand Hygiene Policy requires: "...Personnel must wash their hands or use a waterless alcohol based cleanser in the following situations...before and after each direct patient contact...after removing gloves...."

Observations made on 2B Unit on 12/04/14 at 1130 hours, noted RN Employee #33 entered and exited a patient room without performing any type of hand hygiene.


The Director of Nursing confirmed the above observation during an interview conducted 12/04/14 at 1130 hours.

The Infection Preventionist confirmed during an interview conducted 12/04/14, that the hospital policy follows the Center for Disease Control (CDC) guidelines. However; during the infection control training of the hospital, personnel are instructed to "gel in, gel out" meaning before entering or exiting a patient occupied room.