HospitalInspections.org

Based on medical record reviews, observations, interviews, review of manufacturer's instructions, and policy reviews, the facility failed to follow the facility's infection control policies and procedures for three (#2, #3, and #4) patients of nine patients reviewed, and failed to properly "pre-soak" dirty surgical instuments, and failed to develop a facility policy for healthcare personnel colonized or infected with Multi-Drug Resistent Organisms.

The findings included:


Medical Record review revealed Patient #2 was admitted to the facility on August 21, 2012, with diagnosis of Biliary Dyskinesia and had a Laproscopic Cholecystectomy performed on August 21, 2012.

Observations of Patient #2, in Operating Room #4 (OR #4), on August 21, 2012, at 1:29 p.m., with the Director of Peri-operative Services present, revealed Circulating Nurse #1 (CN #1) removed gloves after counting bloody sponges and did not clean hands before handling the medical record and computer.

Interview with the Director of Peri-operative Services, in OR #4, on August 21, 2012, at 1:35 p.m. confirmed CN #1 did not clean hands after removing gloves worn while counting bloody sponges. Further interview with the director confirmed staff were to clean hands immediately after removing gloves.

Interview with the Infection Prevention Coordinator, on August 22, 2012, at 11:15 a.m., in the Administration Conference Room, confirmed all employees were to immediately clean their hands following removal of gloves after a procedure involving contact with body fluids.

Review of the facility's policy titled, "Hand Hygiene", effective date November 1993, revealed, "All employees will utilize proper hand washing and/or sanitizing techniques ...after body fluid exposure risk ...after touching patient surroundings."


Observations of OR #4, on August 21, 2012 at 2:00 p.m., revealed Surgical Technician #2, placed the dirty surgical instruments in a plastic container with an unknown amount of water and added seven pumped squirts of Aseptizyme (a concentrated enzymatic detergent used to clean body fluids and tissue from instruments) to the container.

Interview with Surgical Technician #2, in OR #4, on August 21, 2012, at 2:00 p.m. revealed the water and Aseptizyme were added to the plastic container to "pre-soak" the instruments prior to cleaning. Further interview with the technician revealed the amounts of water and Aseptizyme added were not measured, and the technician added "enough water to cover the instruments, and then added 3-4 squirts of Aseptizyme".

Review of the manufacturer's instructions revealed "1/2 fluid ounce to one ounce of Aseptizyme to one gallon of water" should be used to "pre-soak" surgical instruments.


Medical Record review revealed Patient #3 was admitted to the facility on August 21, 2012, with a diagnosis of Spinal Stenosis.

Observation of Patient #3, during a spinal Injection procedure (medication is injected into the spine to relieve pain), in the Radiology Department's Procedure Room, on August 21, 2012, at 10:55 a.m., revealed Surgical Technician #1 removed the dust cover/caps from three vials of Depo Medrol (an injectable steroid) and did not clean the rubber septums (rubber covered opening through which a needle is inserted to remove medication from the vial) of the vials prior to the physician drawing the medication from the vial.

Interview with Surgical Technician #1, on August 21, 2012, at 10:57 a.m., confirmed the vial septums had not been cleaned with alcohol before piercing the septum with the needle.

Interview with the Infection Prevention Coordinator, on August 22, 2012, at 11:00 a.m., in the Administration Conference Room, confirmed vial septums were to be cleaned with alcohol prior to being pierced with a needle.

Review of a facility policy named, "Mixing drugs...using a multidose vial...", revision date July 7, 2012, revealed, "Remove the medication vial's lid...Disinfect the stopper with an alchohol pad...".


Observations of Licensed Practical Nurse (LPN) #1, during medication administration on the fifth floor, on August 22, 2012, at 10:15 a.m., revealed the LPN, performed blood glucose testing (determined the amount of sugar in the blood level), on Patient #4, using a glucometer (a device used to measure the amount of sugar in the patient's blood), in the patient's room. Continued observation revealed the LPN did not clean the glucometer after leaving the patient's room and before returning it to the storage case.

Interview with LPN #1, on August 22, 2012, at the Fifth Floor Nurses Station, at 10:16 a.m., confirmed the nurse had not cleaned the glucometer before returning it to the storage case. Further interview revealed the nurse usually cleaned the glucometer with "soap and water".

Continued observations of LPN #1, on August 22, 2012, at 10:17 a.m., revealed the nurse obtained some hand sanitizer, on a paper towel, and used it to clean the glucometer, and then returned it to the storage case. Review of the hand cleanser contents revealed "61% Ethyl Alcohol".

Review of the facility's "Competency Validation & Assessment Checklist" revealed the care and maintenance of the glucometer required, "Use 10% Bleach or Super Sani-Cloth to clean and disinfect meter ...Clean and disinfect meter after every patient use."

Review of the glucometer manufacturer's instructions for cleaning the device revealed, "Do not use alcohol ..." and "Wipe ...with a 10% bleach solution."

Interview with the Infection Prevention Coordinator, on August 22, 2012, at 11:10 a.m., in the Administration Conference Room, confirmed the glucometers were to be cleaned after each patient use, with Sani-Cloth wipes (an EPA approved cleanser), prior to be being stored.


Interview with the Infection Prevention Coordinator, on August 22, 2012, at 11:50 a.m., in the Administration Conference Room, revealed the facility does not have a policy for identifying and isolating healthcare personnel identified by laboratory culture as colonized or infected with Multi-Drug Resistant Organisms.


.