HospitalInspections.org

Based on observation, staff interview and record review the quality assurance program and training programs and hospital infection control program failed to coordinate systems for hospital-wide surveillance and for the prevention of infectious contamination. The outcome of this lack of coordination was a break down in the surveillance program of the sterile processing procedures, the storage of surgical instrument, as well as a lack of feedback to the leadership of the hospital.

Findings:

During a State Relicensing survey from 3/13/17 to 3/16/17, soiled laryngoscopes were observed stored in a clean utility room, high level cleaning of flexible scopes was not done according to guidelines, and the rooms used to clean surgical instruments were not cleaned on a regular basis.

During an interview with the Director of Quality on 3/21/17, there was discussion as to how the Infection Control Program with its hospital-wide surveillance could have overlooked a key area of prevention, the sterilization of surgical instruments. While there were no immediate answers, there was a lack of communication between Infection Control and the Quality departments, as evidenced by the lack of reporting of Infection Control concerns to the Quality Department, the lack of official Infection Control meetings and the lack of involvement of other departments or individuals with the Infection Control Program to form a multi-disciplinary committee. This lack of input from Quality and representatives from other departments was a contributing factor to the omission of the sterile processing unit from the overall hospital infection control surveillance program.