HospitalInspections.org

25107

Based on observation, interview, record review, and policy review, the provider failed to ensure two of two sterilizers were maintained and cleaned according to the provider's policy and manufacturer's recommendations.
Findings include:

1. Interview, observation, and review of the provider's sterilizers operator manual on 6/7/11 at 2:00 p.m. with the infection control nurse, central services technician, and the director of central services revealed:
*The provider was operating two Amsco sterilizers.
*They did portions of the daily maintenance listed in the operator manual for those two sterilizers.
*The maintenance man was responsible for the weekly and monthly maintenance of the sterilizers.
*Housekeeping was responsible for the cleaning of the sterilizers.
*They were not aware of any documentation for the maintenance or cleaning of the sterilizers.

Interview and observation on 6/8/11 at 8:25 a.m. with the director of maintenance revealed:
*He was responsible for maintaining the sterilizers.
*He had done periodic descaling of the sterilizers.
*He had not conducted and was not aware of the weekly or monthly preventive maintenance listed in the operators manual.
*He repaired the sterilizers when they were not working but had not documented when he worked on them.
*There were no service contracts for the maintenance of the sterilizers. He would only contact an outside repair/maintenance source if he could not repair the sterilizers himself.
*He stated the sterilizers had multiple fail safes and would not operate if something was wrong, therefore preventative maintenance was not required.
*A sticky note was posted on the wall in the sterilizer service room with a date of 9/7/10 with no description provided. The maintenance man stated that was when the last descaling had been performed. He had not kept any log for repairs or preventative maintenance of the sterilizers.

Interview and record review on 6/8/11 at 8:30 a.m. with the head of housekeeping revealed:
*Housekeeping was responsible for cleaning the sterilizers.
*She stated the sterilizers were on the weekly cleaning schedule provided to the housekeeping staff.
*The sterilizers were not cleaned every week when the housekeeping staff were busy.
*The last time the housekeeping checklist documented the weekly cleaning of the two sterilizers was 5/13/11.

Review of the sterilizer cleaning policy dated February 2008 revealed the sterilizers were to be cleaned once a week.

27457

Based on observation, interview, and policy review, the provider failed to ensure:
*Medications were properly secured in one of one post anesthesia recovery (PAR) area.
*Intravenous fluids and pour bottle fluids were properly stored and warmed for one of one operating room suite and one of one emergency room suite.
Findings include:

1. Observation on 6/7/11 at 8:00 a.m. of the PAR area revealed the following medications were being stored unsecured in the cabinets next to the sink:
-Six vials marcaine 0.25 percent.
-Ten vials depo-medrol.
-One vial flumazenil.
-Two carpujects naxolone.

Interview on 6/7/11 at 1:35 p.m. with the director of nursing (DON) revealed:
*She agreed the medications found above should have been secured.
*She had ordered locks to be installed on those cabinets some time ago, but they had not been installed. She was not aware they had not been installed as ordered.
*The provider's policies required all medications to be secured.

2. Observation on 6/7/11 at 12:25 p.m. of the blanket/fluid warmer in the operating suite revealed:
*The warmers interior temperature was 114 degrees Fahrenheit (F).
*No log was on the warmer noting monitoring of the warmers interior temperature.
*The warmer had multiple bottles of different sized normal saline and sterile water in it.
*The warmer had multiple bags of different sized normal saline and lactated ringers intravenous fluid in it.
*Two 500 milliliter bags of normal saline were noted to be expanded to the point that the exterior plastic of the bag was stretched like a balloon.
*None of the bottles had marks of any kind on them that indicated the date when the fluid had been placed in the warmer.

Interview and observation on 6/7/11 at 12:35 p.m. with registered nurse A revealed:
*She was one of the surgical areas primary surgical nurses.
*No process was in place to indicate when fluids were placed into the warmer or when they were removed.
*The warmer temperature was not monitored.
*She was not aware the 500 milliliter bags of saline had expanded as noted above.
*She was not aware of any policy related to warming fluids.
*She was not aware of the standards for fluid warming.

3. Observation on 6/7/11 at 1:30 p.m. of the blanket/fluid warmer in the emergency room suite revealed:
*The warmers temperature was 96 degrees F.
*No log was on the warmer noting monitoring of the warmers temperature.
*The warmer had multiple bottles of different sized normal saline and sterile water in it.
*None of the bottles had marks of any kind on them that indicated the date when the fluid had been placed in the warmer.

Interview on 6/8/11 at 9:30 a.m. with the DON confirmed no policy and procedure existed related to the warming of fluids.

Review of the Association of periOperative Registered Nurses, Perioperative Standards and Recommended Practices, 2010 Edition, Denver, CO, pages 224 and 225, revealed:
*Warming cabinet temperatures should be monitored at regular intervals.
*Setting, maintaining, and monitoring of warming cabinets should be assigned to specific personnel.
*The warming cabinet should be labeled with safe operating temperatures if fluids were stored in it.
*Only fluids that were approved to be warmed by the manufacturer should have been warmed.
*Fluids stored in a warmer should have been labeled with the date they were placed in the warmer and the date they should have been pulled from the warmer as per the manufacturer's recommendations.
*Warmed fluids used as irrigation and intravenous injection should not exceed normal body temperature.

Based on observation, interview, and policy review, the provider failed to ensure:
*Multiple medications used in the operating and procedure rooms were checked for expiration dates and removed from service.
*Multiple-dose vials were properly labeled after being placed into service.
Findings include:

1. Observation on 6/7/11 at 8:50 a.m. of the procedure room anesthesia medication cart revealed:
*Two ampules of marcaine (spinal injection) outdated on 2/1/11.
*One vial of etomidate outdated in May 2011.

Interview on 6/7/11 at 8:55 a.m. with certified nurse anesthetist (CRNA) B revealed:
*Pharmacy did not stock or check medications for outdates for anesthesia.
*When medications were needed by anesthesia services CRNA B would access the pharmacy to replenish the supply.
*He was responsible for checking medications for outdates.

Observation on 6/7/11 beginning at 12:25 p.m. of the operating room medication cabinet, the operating room anesthesia medication cart, and the operating suite refrigerator located in the dirty utility room revealed:
*The operating room medication cabinet contained:
-One vial marcaine 0.5 percent (%) outdated on 3/10/11.
-Five vials of methylene blue 1% were outdated.
-A vial of dexamethasone was opened and half used. That vial was unlabeled as to when it had been opened.
*The anesthesia cart contained:
-A vial of naxolone was opened and partially used. That vial was unlabeled as to when it had been opened.
-One ampule of 5% lidocaine and 7.5% dextrose outdated on 5/1/11.
-Two vials of gluca-gen outdated May 2011.
-Two ampules of nalbuphine outdated on 2/1/11.
-One l% lidocaine outdated on 5/1/11.
-One vial of midazolam was opened and partially used. That vial was unlabeled as to when it had been opened.
-One vial of xylocaine-MPF 1% outdated on October 2010.
-One bottle of liquid forane for inhalation outdated on August 2010.
*The operating suite refrigerator contained:
-Flumazenil vials that were opened and partially used. Those vials were unlabeled as to when they had been opened.
-Four vials of atracurium outdated on May 2011.
-One vial of anectine was opened and partially used. That vial was unlabeled as to when it had been opened.
-Two vials of rocuronium bromide outdated April 2011.
*The refrigerator located in the dirty utility room contained multiple temperature sensitive medications. The refrigerators temperature was not monitored or logged. No thermometer was located in the refrigerator.

Interview and policy review throughout the survey with the director of nursing revealed:
*The outdated medications found above should have been removed from service.
*Multiple-dose vials should have been labeled with the date they had been opened, and then disposed of after 28 days of service.
*The provider had not followed its policy on outdated and discontinued drugs.
*The provider had not followed its policy on multiple/single use vials.
*She agreed the refrigerator temperature in the operating suite dirty utility room should had been monitored and logged.

Based on observation and interview, the provider failed to ensure:
*Use an appropriate chemical for the disinfecting of critical and semi-critical instruments.
*Clean community use equipment between patients.
*Label chemical containers.
*Ensure the appropriate contact time was met for the use of a disinfectant.
*Clean the hydrocolator according to manufacturer's directions.
*Maintain the clean environment of the central services room.
*The results of the control portion of the sterilizers biological testing was documented.
*Staff were knowledgeable regarding the process of recalling instruments in the event of a positive biological test.
*The infection control nurse monitored and observed the sterilization process.
*Properly cleanse intravenous ports prior to use.
*Clean supplies were stored in a hygienic manner in one of one procedure room and in one of one decontamination room.
Findings include:

1. Interview on 6/7/11 at 2:15 p.m. with the infection control nurse in the operating room instrument decontamination room revealed:
*She had not directly observed decontamination of instruments.
*She did not believe the quaternary ammonia product located on the decontamination sink was currently being used. She stated that product should not be used in the decontamination process.

Interview and label review on 6/8/11 at 8:54 a.m. in the decontamination area of the operating room suite with registered nurse A revealed:
*Instruments cleaned in the decontamination area went into the patient's body and were considered critical or semi-critical instruments.
*The instruments were cleaned with the Enzol detergent, rinsed, then soaked in the quaternary ammonia for ten minutes, and then placed into a lubrication bath.
*Review of the label for the quaternary ammonia disinfectant revealed it was not to be used on critical or semi-critical instruments.

Review of the Association of periOperative Registered Nurses, Perioperative Standards and Recommended Practices, 2010 Edition, Denver, CO, page 427, revealed "Cleaning agent manufacturers' written instructions should be followed."

2. Observation on 6/7/11 at 1:30 p.m. revealed one blood draw chair in the laboratory.
Interview with certified laboratory technician D at that time revealed:
*The chair was cleaned multiple times a day with dispatch disinfectant wipes.
*The chair was not cleaned after every patient.
*She was not aware the chair should have been cleaned after every patient.
Further observation revealed there was no disinfecting wipes located near the blood draw chair.

Interview on 6/7/11 at 2:00 p.m. with the infection control nurse revealed the blood draw chair should have been disinfected after every use.

Review of the policy for care of articles and equipment dated March 2010 revealed patient equipment would be cleaned and disinfected after each patient use.

3. Observation on 6/7/11 at the following times revealed:
*The provider used the Wettask wiping cloth system.
*At 9:10 a.m. one Wettask wiping bucket in the ultrasound room was labeled Oxiver and tested positive for quaternary ammonia.
*At 9:15 a.m. one Wettask wiping bucket in the soiled utility was labeled Oxiver and tested positive for quaternary ammonia.
*At 9:20 a.m. one Wettask wiping bucket in prep room 2 was labeled Oxiver and tested positive for chlorine.
*At 10:00 a.m. two Wettask wiping buckets in the physical therapy (PT) area were labeled PT and had no chemical identification.

Interview on 6/7/11 at 9:29 a.m. with the head of housekeeping revealed:
*Oxiver was the old chemical the provider had used in the Wettask buckets and was no longer being purchased.
*They were using the last of the Oxiver up and transitioning to a quaternary ammonia product.
*A 3M twist and fill quaternary ammonia product was the chemical the hospital was now using in the Wettask buckets.
*She knew all chemical containers should be labeled with the contents.
*She did not know why the Wettask containers were not being re-labeled when they were being refilled.

4. Observation on 6/7/11 at 10:00 a.m. revealed two Wettask wiping buckets in the PT area.

Interview on 6/7/11 at 10:03 a.m. with PT technician C revealed:
*The Wettask wiping buckets were filled with a quaternary ammonia product.
*They used the Wettask clothes to disinfect the patient use equipment between uses.
*The surface of the equipment would stay wet for less then a minute after being wiped with a Wettask wiping cloth.

Review of the label for 3M twist and fill 25L, the quaternary product used to fill the Wettask wiping cloth buckets, revealed the surfaces of equipment should remain wet for 10 minutes to disinfect.

5. Interview and observation on 6/7/11 at 10:03 a.m. with PT technician C revealed:
*A hydrocolator in the PT area.
*She cleaned the hydrocolator.
*The hydrocolator was cleaned twice a year.
*She was not aware of a policy and procedure for the cleaning or maintenance of the hydrocolator.
*She was not aware of the manufacturer's instructions for the cleaning of the hydrocolator.

Interview on 6/7/11 at 11: 30 a.m. with the director of PT revealed:
*She was in the process of updating the policy and procedures for PT.
*The old policy was not very well written, and she had discarded it.
*Currently there was no policy for the cleaning of the hydrocolator.

Review of the operator's manual for the hydrocolator revealed it was to be cleaned at a minimum of every two weeks.

6. Observation on 6/7/11 at 12:05 p.m. of the sterilization room revealed:
*Multiple corrugated cardboard shipping boxes of copy paper were stored on the floor next to the sink (photo 1).
*Office supplies were stored in and on top of the cabinets (photos 2 and 3).
*Access to the room was not limited to surgical and sterilization personnel.

Interview on 6/7/11 at 2:10 p.m. with the infection control nurse, central services technician, and the director of central services revealed:
*The sterilization room was being used to store office supplies. The director of central services stated they were using the sterilization room for storage due to the lack of space in the main storage area.
*Staff from multiple areas would access the sterilization room for office supplies. They agreed access to the sterilization room should have been limited to surgical and sterilization staff.
*The infection control nurse agreed storing shipping boxes and office supplies in the sterilization room was not hygenic and was a breach in infection control.

Interview and policy review on 6/8/11 at 9:20 a.m. with the administrator and DON revealed:
*They were aware office supplies were stored in the sterilization room.
*They stated the supplies were stored there for convenience for other hospital personnel.
*The DON revealed there was no policy and procedure related to storage of dirty/outside supplies in the sterilization room.

Review of the International Association of Healthcare Central Service Material Management, Central Service Technical Manual, 7th Ed., Chicago, Illinois, page 106 and 109, revealed:
*"The first step in maintaining environmental integrity is to control the traffic that enters and passes through the Central Services department."
*"Corrugated boxes should not be allowed in work areas."

7. Interview and sterilizer testing log review on 6/7/11 at 2:15 p.m. with the infection control nurse, director of central services, and the central services technician revealed:
*The log had a space for recording the biological control. The control portion of the biological testing of the sterilizers was not being recorded.
*They did not know why they had not been recording the biological control result.
*They agreed the results of the control portion of the biological log should have been documented.
*They were unable to tell this surveyor what the provider's process would be in the event of a positive biological test of the sterilizers. However they thought they would call the head of maintenance.
*They were unaware the infection control nurse should be contacted as soon as a positive biological test was noted.
*The central services technician had been trained by on-the-job training. That training was not documented in her personnel file.
*The sterilization personnel did not receive annual training related to sterilization nor was competency testing performed.
*The infection control nurse stated she did not review the sterilizer testing logs to ensure the efficacy of the two sterilizers and proper documentation of all testing.
*The infection control nurse did not observe the sterilization process conducted by central services personnel to ensure proper technique of sterilization was followed.
*The infection control nurse had limited involvement in the sterilization process.



27457

8. Observation on 6/7/11 beginning at 8:45 a.m. of certified registered nurse anesthetist B during patient 19's colonoscopy revealed:
*He had not disinfected/cleansed the patient heparin lock prior to attaching the intravenous fluid line.
*He had not disinfected/cleansed the intravenous ports of the intravenous tubing prior to administering medications multiple times during the course of the case.

Review of the provider's revised June 2011 policy on intravenous-heparin/saline lock procedure revealed intravenous ports were to be cleansed with alcohol prior to each access.

9. Observation on 6/7/11 at 9:00 a.m. of the gastrointestinal scopes located in the procedure room revealed:
*They were hung to dry directly above clean and sterile supplies (photo 4).
*Stained white towels were located at the bottom of the cabinet (photo 4).

Interviews on 6/7/11 beginning at 1:35 p.m. with the director of nursing (DON) and the infection control nurse revealed:
*They both agreed the above found supplies should not have been stored under the gastrointestinal scopes.
*They were unsure as to when or how often the towels at the bottom of the gastrointestinal scope cabinets were changed and how often the cabinets were cleaned and disinfected.
*The infection control nurse agreed the storage of supplies with the gastrointestinal scopes was a breach in good infection control practices.

10. Observation on 6/7/11 beginning at 12:35 p.m. of the dirty utility room in the surgical suite revealed the following clean items were being stored in the dirty utility room where surgical instruments were cleaned: medications, intravenous fluids, surgical scrubs, surgical gowns, clean linen, respiratory supplies and a refrigerator that stored medications.

Interviews on 6/7/11 beginning at 1:35 p.m. with the DON and infection control nurse revealed:
*They both agreed clean supplies should never be stored in a dirty utility room due to the risk of cross-contamination.
*The infection control nurse agreed storing clean supplies in the operating suite dirty utility room was a breach in good infection control practices.

Review of the Association of periOperative Registered Nurses, Perioperative Standards and Recommended Practices, 2010 Edition, Denver, CO, pages 225 and 226, revealed "Physical separation from areas where clean items are handled minimizes the risk of cross-contamination."

Based on observation, testing, and interview, the provider failed to mix the chlorine sanitizing water at an appropriate and safe level for one of one wiping cloth buckets in the dietary department. Findings include:

1. Observation on 6/7/11 at 1:40 p.m. revealed a wiping cloth bucket in the dietary department. Testing of the chlorine level with this surveyor's test strip revealed the chlorine was over 200 parts per million (ppm).

Interview on 6/7/11 at 1:50 p.m. with the certified dietary manager revealed:
*She knew what strength the chlorine sanitizer should be mixed at.
*The mixture was made by one of the two morning cooks, and both cooks were gone for the day.
*She was not aware the chlorine was mixed too strong.

Testing of the chlorine solution at that time by the certified dietary manager with the provider's chlorine test strips revealed the solution was so strong that the strip bleached out and turned white.

Based on interview and record review, the provider failed to ensure policies were reviewed annually for 3 of 15 departments reviewed (sterilization/central supply, laundry, and housekeeping). Findings include:

1. Review of the policies and procedures for the sterilization/central supply department revealed the policies and procedures for that department had not been updated since 2/2/08.

Interview on 6/8/11 at 9:15 a.m. with the central supply manager revealed she confirmed the sterilization/central supply policies and procedures had not been updated since 2/2/08.



25107

2. Review of the policies and procedures for housekeeping and laundry revealed:
*There was no sheet identifying when the policies and procedures had last been reviewed for either department.
*The majority of the policies were dated 2006.
*Some were dated prior to 2006.

Interview on 6/8/11 at 11:00 a.m. with the department head for housekeeping and laundry revealed the policies and procedures were last reviewed approximately four years ago.