HospitalInspections.org

Based on observations, records reviewed and interviews the Hospital failed to consistently adhere to infection control standards in hand hygiene and disinfection practices.
Findings included:

1) The Surveyor observed Patient #2 undergo an endoscopic retrograde cholangiopancreatography (an ERCP is a procedure that enables your physician to examine the pancreatic and bile ducts using a bendable, lighted tube) on 7/6/16 at 1:45 P.M. in the Endoscopy Procedure Room.

At 2:22 P.M. Physician #2 was observed replacing the peripheral intravenous (IV) line in Patient #2's left arm. Physician #2 wore gloves, as required, when inserting the IV. Physician #2 failed to remove his gloves and perform hand hygiene as required. At 2:29 P.M., Physician #2 entered the clean anesthesia cart wearing one of the gloves used to insert Patient #2's IV. Physician #2 failed to remove his soiled glove and perform hand hygiene prior to entering the clean anesthesia cart. At 2:39 Physician #2 entered the clean automated medication dispenser and retrieved medication for Patient #2, again with one hand remaining gloved and holding the glove he removed from his other hand. Physician #2 failed to perform hand hygiene prior to entering the clean medication dispenser. At 2:50 Physician #2 donned gloves and suctioned Patient #2. Physician #2 then re-entered the clean anesthesia supply cart without removing the gloves used during Patient #2's suctioning procedure. At 2:56 P.M. Physician #2 removed his gloves, failed to perform hand hygiene and re-entered the automated medication dispenser. The hand hygiene dispenser was wall mounted approximately three feet from Physician #2's work area.

The Surveyor interviewed the Manager of the Infection Prevention Department at 7:30 AM on 7/7/16. The Infection Prevention Director said both the anesthesia supply cart and the automated medication dispenser were considered clean areas and hand hygiene would be expected prior to entering either site.

2) The Surveyor interviewed Central Sterile Technician #1 at 11:20 A.M. on 7/6/16 in the decontamination area of the Central Sterile Supply Department. Central Sterile Technician #1 said she might be called upon to perform manual High Level Disinfection (a chemical process that eliminates virtually all recognized pathogenic microorganisms except for spores) on instruments that required reprocessing between patients. Central Sterile Technician #1 reviewed the multiple steps (i.e. monitoring for the chemical efficacy, timing and temperature) to accomplish High Level Disinfection. Central Sterile Technician #1 said at the completion of the chemical process instruments were immersed in clean water then vigorously rinsed with the hand-held sprayer. According to the manufacturer's directions for use rinsing must be done using three immersion baths changing to clean water with each immersion.

The Surveyor interviewed the Manager of the Central Sterile Department at 11:00 A.M. on 7/7/16. The Surveyor and the Manager of the Central Sterile Department reviewed the manufacturer's directions for use and confirmed the rinsing process of three separate immersion baths to ensure no chemical residue remained on the instrument.

3) The Surveyor toured the Operating Room on 7/6/16. Observations in the sub-sterile room at 10:00 A.M. revealed a dark discolored and sticky residue on the counter next to the steam sterilizer. The Director of Surgical Services said it might be due to the use of patient stickers to complete the Immediate Use Sterilization Log and was aware that with this sticky debris present, the counter could not be effectively cleaned and disinfected.

The Surveyor observed the Endoscopy Treatment Room #1 at 1:45 P.M. on 7/6/16. The counter on the left wall was darkened and sticky with tape or sticker debris. The counter could not be effectively cleaned and disinfected between patients using Treatment Room #1.