HospitalInspections.org

Based on observation, interview, and record review, the hospital failed to provide personal privacy when the hospital disclosed medical condition information on white boards in patient's rooms clearly visible to other patients, visitors and hospital staff, and failed to secure patient records in patient care areas.

These failures had the potential to disclose protected patient private health information to other staff and visitors.

Findings:

During an observation and concurrent interview with the Risk Manager (RM), on 1/05/16 at 2:30 PM in the hospital Medical Surgical Floor, a room with four patient beds had a wall with two large white boards. A visitor was standing in front of the boards reading them. Patient 6's board indicated he had a heart monitor on, he had a supra-pubic catheter (drains urine from the bladder) which needed to be irrigated frequently, he was taking antibiotics (medication for an infection), and he required oxygen. Patient 7's board indicated the patient was diabetic, needed intravenous antibiotics and breathing treatments. The RM stated the medical information would be removed from the boards.

During an observation of the radiology department on 1/4/16 at 11 AM, in X-ray Room 2 a CD with a patient name and number identified as a Mammogram was found in a patient bedside table. The outpatient ultrasound room had a total of 40 patient records including patient names and diagnosis in a notebook on a desk assessable to other patients, visitors and staff. The RM stated all patient medical information would be removed and placed in a secure area.

The hospital policy and procedure titled "Medical Records" dated 7/25/14, indicated "The hospital shall safeguard information in the record against....or use by unauthorized persons, including records filed in a hospital department."



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Based on observation, interview, and document review, the hospital failed to have accurate content lists of medications posted on several emergency crash carts in the hospital's departments. These failures could potentially increase risk for adverse outcomes for patients during medical emergencies.

Findings:

During an observation on 1/5/16 at 11:05 AM, in the Medical Surgical (MedSurg) department, the medication content list posted on the adult emergency crash cart was examined with the Director of Pharmacy (DP). The list was then compared with the content of each medication tray inside the top drawer of the emergency crash cart. In the crash cart was one injectable vial of Benadryl (drug used for the relief of various allergic conditions) 50 mg/ml, one injectable vial of Furosemide (drug used to treat excessive fluid accumulation and swelling of the body) 40 mg/4 ml, and one 250 ml bag of normal saline (Sodium Chloride 0.9% intravenously fluid.) These medications were not listed on the content list that was posted.

Further inspection of emergency crash carts in other nursing units with the DP revealed that one adult crash cart (crash cart 2) in the Intensive Care Unit (ICU), one adult crash cart 12 in the Department of Obstetrics (OB), and one pediatric crash cart in the Emergency Department (ED) did not have a medication content list posted outside. While the other adult emergency crash cart (crash cart 4) in the ICU did not contain par levels (the minimum quantity of an item stocked) for both Furosemide and Benadryl medications on the list.

During an interview with DP on 1/5/16 at 11:50 AM, he acknowledged the medication lists outside of both emergency crash carts in the ICU and MedSurg unit were outdated.

According to the California Code of Regulations Title 22, under 70263 (f)(2), it states "...The contents of the container shall be listed on the outside cover and shall include the earliest expiration date of any drugs within."

Based on observation, interview, and document review, the hospital failed to ensure outdated medication was removed from one location in the hospital. This failure had the potential to place patients of receiving medications that were no longer affective or had lost their potency.

Findings:

The hospital policy titled "Expired Medications" indicated "No medication will be kept in stock after the expiration date on the label." It further indicated under the Procedure section, "The Pharmacy shall keep all expired medications separate from other medication stock until such time as they can be returned for credit or disposed of according to federal and state regulations."

During an observation of the Department of Obstetrics (OB area where babies are delivered) on 1/5/16, at 2:30 PM, with the Director of Pharmacy (DP) and manager of OB (RNM) a 100 ml bottle of isoflurane liquid for inhalation (general anesthetic and muscle relaxant agent) was found in the bottom drawer of an anesthesia cart.

During a concurrent interview with the DP and the RNM at 2:46 PM, they acknowledged the medication should have been removed from the cart and properly disposed of according to hospital policy.



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Based on interview and document review, the hospital failed to have a full-time employee who serves as Director of Dietetic Services and is responsible for daily management of the dietary services. The hospital Dietary Director's job description failed to delineate dietary department duties.

This failure had the potential to contribute to the inability of the Director of Dietetic Services/ Materials Management to adequately direct both operations.

Findings:

During an interview with the hospital Director of Material Management/Dietary Supervisor on 1/6/16 at 12:10 PM, she stated, "I am the Director of both areas, I spend half my time in the kitchen and half my time in the materials management area."

The hospital job description for "Director of Materials Management/Dietary" dated 6/14/11, indicated "Position is the Director of Materials Management, Transportation and Nutritional Services. Provides leadership, supervision throughout the group." The job description contained no specific duties for the direction and responsibility for dietary services.

Based on observation, interview, and document review, the hospital failed to ensure a sanitary environment that prevented the transmission of infections and communicable diseases as evidenced by:

1. Failed to remove expired patient care products from multiple patient care areas. (refer to A 749)

2. Failed to maintain a safe and sanitary environment when non-sterile items were stored with sterile items. Cleaning fluids, electronic equipment, office supplies, x-ray table parts were stored with sterile supplies. Sterile supplies were stored on dirty floors, particle board and on dirty shelves and bins. Outdated, unused, dirty equipment was stored with clean patient supplies. (refer to A 749)

3. Failed to ensure sharps and syringes were disposed of according to hospital policy and nationally accepted standards. Failed to ensure proper usage of bio-hazard containers.(refer to A 749)

4. Failed to follow hospital policy and procedures for isolation precautions and procedures ( measures used to protect staff, patient and visitors from infection). (refer to A 749)

5. Failed to ensure proper sanitizing procedures were followed when staff failed to use cleaning solutions per manufactures guidelines and hospital procedure. Failed to remove torn and damaged mattresses and pillows which were not able to be sanitized. (refer to A 749)

6. Failed to ensure endoscopes were stored in accordance with hospital policy and nationally accepted standards. (refer to A 749)

7. Failed to clean surgical instruments according to disinfectant manufacture's instructions. (refer to A 749)

8. Failed to follow hospital policy for daily assessment of central lines. (refer to A 748)

9. Failed to implement vaccination requirements for health care workers according to nationally accepted standards. (refer to A 748)

The cumulative effects of these systemic failures resulted in the hospital's inability to ensure a sanitary environment, placing all patients, staff and visitors at risk of being exposed to infectious and communicable diseases.



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Based on observation, interview, and document review, the hospital's infection control officer failed to ensure infection control policies for the control of infection and communicable diseases were implemented when:

1. Hospital policy for the daily assessment of ongoing need for central lines was not followed for one of 20 sampled patients (24) and,

2. Vaccination requirements for healthcare workers were not implemented according to national standards adopted by the organization.

These failures resulted in the hospital's inability to ensure a sanitary environment, placing all patients, staff and visitors at risk of being exposed to infectious and communicable diseases.

Findings:

1. During an interview with Infection Control Nurse (ICN) 2, on 1/6/16, at 10:10 AM, the clinical record of Patient 24 was reviewed. Patient 24 had a central line (an intravenous (IV) catheter inserted into a large vein) placed on 1/4/16. There was no documented evidence the patient still required a central line. ICN 2 verified there was no documentation in the Medical Record that indicated the patient had been assessed to determine the ongoing need of his central line.

The hospital policy titled "Central Line Care" dated 10/29/15, indicated a Registered Nurse is to do a daily assessment of the patient's need for the central line, and communicate daily to the physician to determine the ongoing need for a central line.

2. During an interview with the ICN and ICN 2, on 1/6/16, at 11:30 AM, they stated the hospital health requirements for healthcare workers does not include measles, mumps, rubella, varicella (Chicken Pox) and Tdap (a combination vaccine that protects against three potentially life-threatening bacterial diseases: tetanus (a serious illness caused by bacteria that can enter the body through a deep cut), diphtheria (a serious bacterial infection), and pertussis (commonly known as Whooping Cough, an infectious bacterial disease that causes uncontrollable coughing).

The hospital policy titled "Pre-Employment Physical, Annual Health Screening, and Other Health Issues" dated 6/6/14, did not include vaccination requirements for measles, mumps, rubella, varicella (Chicken Pox) and Tdap. The policy did not specify if it applied to physicians, vendors, volunteers or students.

During an interview with the Operating Room Director (ORD), on 1/5/16, at 9:30 AM, she stated the hospital adopted the Association of Perioperative Nurses (AORN)Guidelines for Perioperative Practice as their nationally recognized guidelines for their infection control program.

According to the AORN, Perioperative Standards Guideline for Prevention of Transmissible Infections, Recommendation VIII, the Center for Disease Control Advisory Committee for Immunization Practices recommends health care providers receive immunizations if they come into contact with patients or infectious material from patients that may put them at risk for exposure and possible transmission of vaccine-preventable disease. Healthcare personnel should have presumptive evidence of immunity to measles, mumps, and rubella, and this information should be documented and readily available in the healthcare setting. Presumptive evidence includes written documentation of vaccination with two doses of measles-mumps-rubella vaccine administered at least 28 days apart, laboratory evidence of immunity, laboratory confirmation of disease, or birth before 1957. Health care personnel should receive a single dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) as soon as feasible upon hire if they have not been vaccinated previously. Health care organizations should ensure that all health care personnel have evidence of immunity to varicella, and providers who have no evidence of immunity should receive the varicella vaccine. This information should be documented. Health care organizations should review health care provider vaccination and immunity status at the time of hire and at least annually thereafter.

The CDC indicates healthcare workers include physicians, nurses, emergency medical personnel, dental professionals and students, medical and nursing students, laboratory technicians, pharmacists, hospital volunteers, and administrative staff.

Based on observation, interview, and record review, the hospital's infection control officer failed to implement the hospital's infection control policies and procedures and follow nationally recognized infection control guidelines to reduce the risk of developing infections and communicable diseases. The hospital:

1. Failed to remove expired patient care products from multiple patient care areas.

2. Failed to maintain a safe and sanitary environment when non-sterile items were stored with sterile items. Cleaning fluids, electronic equipment, office supplies, x-ray table parts were stored with sterile supplies. Sterile supplies were stored on dirty floors, particle board and on dirty shelves and bins. Outdated, unused, dirty equipment was stored with clean patient supplies.

3. Failed to ensure sharps and syringes were disposed of according to hospital policy and nationally accepted standards. Failed to ensure proper usage of bio-hazard containers.

4. Failed to follow hospital policy and procedures for isolation precautions and procedures
(measures used to protect staff, patient and visitors from infection).

5. Failed to ensure proper sanitizing procedures were followed when staff failed to use cleaning solutions per manufactures guidelines and hospital procedure. Failed to remove torn and damaged mattresses and pillows which were not able to be sanitized.

6. Failed to ensure endoscopes were stored in accordance with hospital policy and nationally accepted standards.

7. Failed to clean surgical instruments according to the enzymatic cleaner manufacturer's instructions.

8. Failed to utilize appropriate disinfection products and failed to use disinfection products according to manufacturer's instructions and nationally accepted standards.

These failures resulted in the hospital's inability to ensure a sanitary environment, placing all patients, staff and visitors at risk of being exposed to infectious and communicable diseases.

Findings:

1. During an observation and concurrent interview with the Risk Manager (RM), Infection Control Nurse (ICN), Director of Pharmacy (DP), and Radiology Supervisor (RS), on 1/4/16, at 9:51 AM, in the Radiology Department, (X-Ray department) the following expired items were found:

In the X-Ray Storage Room:

One gallon container of Cidex OPA, (a solution used to clean instruments and equipment) expired 06/2006.

In X-Ray Room 3:

One bottle of Enfamil Formula (infant formula for feeding), expired 6/2015.
One Devon Surgimark pen (a pen infused with ink used to mark or label skin), expired 3/2012.
One Devon Surgimark pen expired 4/2012.
One intravenous (IV) start kit (a kit used to start an IV access, including sterile dressings, skin cleaner, and tape), expired 2/2015.
Two one-gallon containers of Alkaline Water (water that has less acid than regular tap water) used for equipment calibration (testing equipment), dated by manufacturer best if used by 9/11/15.

In the X-Ray Reading Room:

Four Chiba needles (flexible needle used to enter a very small blood vessel or take a tissue sample), expired 8/2012.

In the X-Ray hallway crash cart (used for patient medical emergencies):

One package of open electrocardiogram (ECG) Electrodes, (foam or paper pad placed on the skin of arms, legs, and chest, during a test to record activity from the heart every time it beats), expired 2/2008.

The RM and ICN stated they would remove the expired items and dispose of them.

During observation and concurrent interview with the hospital RM, ICN, and Manager Obstetrics/Gynecology (RNM), on 1/5/16, at 2:30 PM, the following was found:

In the Obstetrics (the department that cares for women giving birth) supply storage closet the following was found:

One Kendall Argyle Suction Handle, (flexible, bendable, plastic tube used for suction), expired 4/2015.

In the Triage Room, (a room where a patient is first evaluated), the following was found:
Six Red top Blood Collection Tubes, (sterile tube for collecting a blood sample for testing), expired 10/2012.

The RM stated all expired products will be disposed of.

During an observation and concurrent interview with the RM, ICN, and Director of Laboratory Services (DLS), on 1/4/16, at 3:50 PM, in a storage closet outside of the laboratory staff break-room, the following was found:

Five cases (120 total devices) Profile Drug Screening Devices (a test for one or more drugs in human urine), expired 4/2015.

The RM stated all expired products will be disposed of.

During observation and concurrent interview with the RM, RS and MRI Technician (MRIT), on 1/5/16, at 2:50 PM, of the MRI (an examination that provides images of the body) room the following was found: One open package of cardiac electrodes (used to read a patients heart rhythm) expired 9/2008. One box of 25 vacutainers (used to draw blood from a patient's vein) expired 9/2008. One box of 12 vacutainers expired on 9/2008. Four IV start kits (a supply kit used to start an IV, including sterile dressings, skin cleaner, and tape), expired 7/2015. Four Intravenous dressing kits expired 7/2009.

The RS stated all expired products will be removed.

The hospital policy and procedure titled "Materials Management" dated 4/23/14, indicated "All products with expiration dates stocked on the patient care floors will be monitored on a daily basis... Expired products should be handled immediately, disposed, returned..."

2. During an observation and concurrent review with the RM, ICN, DP, and RS, on 1/4/16, at 9:51 AM, in the X-Ray Department, the following was found:

An unlabeled storage closet in the Radiology hallway contained two 20 inch by 20 inch by 20 inch deep white plastic containers with rust colored stains, the top container contained three inches of off-white and rust colored plastic marble sized balls. Connected to the containers were two hoses going to a floor drain which contained rust colored grime. Next to the floor drain on the ground was a black fabric container with patient care equipment and a unlabeled clear plastic spray bottle with a clear liquid.

The RS stated she did not know what the plastic containers and drain were used for. "It's something we should have gotten rid of a long time ago."

A second unlabeled storage closet contained a metal cart blocking the doorway. On top of the cart were multiple patient towels with a brown hat, coat, a blue surgery disposable head cover, car keys, coffee cup, and a piece of X-Ray table equipment. Behind the cart, accessible by a second door was a set of staff lockers, one of which contained an opened bottle of betadine solution (disinfectant), three bottles of Hydrogen Peroxide, one package of crazy glue, two silicone sprays, three energy drinks and a jar of spaghetti sauce.

In the X-Ray Storage Room:

Multiple sterile syringes and personal protective gowns (gowns used to minimize exposure to blood and body fluids) were observed stored next to Clorox Wipes (disposable material saturated with disinfectant) and above patient procedure gloves.
Two containers of hand sanitizer (antibacterial solution used to sanitize hands) stored on a particle board shelf with clean patient equipment, and sterile gloves.
Two sterile Argyle Suction Handles (flexible, bendable plastic tube used for suction) in the same storage bin with two unsterile plastic suction canisters (a plastic container to collect fluids).

In X-Ray Room 3:

One Enfamil formula (infant formula for feeding) stored next to seven bottles of Gastrografin (fluid used during X-Rays of the stomach and bowel to help locate bleeding, obstructions, or tumors) labeled DO NOT INJECT in large red letters.
Four Sterile Cone Instruments (X-Ray supplies for testing) packages wrapped tightly with a rubber band, compromising the sterility by folding the package edges, and mixed with four unsterile cables.
Multiple cables, patient positioning equipment, and table parts, were stored next to sterile supplies in a dusty metal cabinet.

The RS stated she would re-organize the shelves so sterile items would be stored in a safe manner.

In X-Ray Room 2:

Two gallons of Cidex OPA (a solution used to clean instruments and equipment) stored next to two sterile packs (packs include sterile instruments and sterile dressings packaged for patient use).

During an observation and concurrent interview with the RM and the RNM, on 1/5/16, at 2:30 PM, the following was found:

In Obstetrics (the department that cares for women giving birth) the supply storage closet leading to the Delivery Room was filled to the ceiling with sterile surgical packs (packs containing sterile gowns, towels syringes, solutions, and dressings used during a delivery). The floor of the closet had a gray grimy matter with a dusty step stool and a grimy, dusty white plastic tray on the floor. Laying on the step stool were several surgical packs. Several packs were touching the floor. The RNM stated she would clean up the closet. The door leading to the Delivery Room had two red bins identified with signs saying Bio-hazard Waste (contaminated items that were used for patient care). On top of the bins were multiple carpentry tools including a drill.

During an observation, and concurrent interview with the RM and RS, on 1/5/16, at 3:20 PM, in the 4 D Ultrasound Room, there were six reams of paper stored next to four gallons of Cidex OPA (a solution used to clean instruments and equipment) and a portable room heater next to the linen cart.

During an observation and concurrent interview with the RM and RS, on 1/5/16, at 3:43 PM, in the Nuclear Medicine Department, there were two torn pillows, with the interior pillow material exposed, on a patient exam table. A blue bin on an open shelf contained an opened package of expired patient cardiac electrodes (foam or paper pad placed on the skin of arms, legs, and chest, during a test to record activity from the heart every time it beats), multiple plastic bags, a roll of patient tape and multiple vacutainers (a sterile device used to collect blood samples). The blue bin contained gray matter, dust, and multiple dead insects and insect parts. There was also an open metal cabinet that contained three blue storage bins and one green storage bin. All of the bins contained various patient supplies and equipment, including several three lead cardiac monitoring cables, multiple additional patient cables, and rolls of patient tape. All bins had dusty gray matter and multiple dead insects inside them. Next to the bins was an open package of two inch by two inch patient dressings. The RS stated the package of dressings should be single patient use then discarded. The top of the supply storage cabinet containing the blue and green bins was rusted with peeling paint. Two plastic bins on the bottom of the supply cart had various plastic patient masks and tubings that were covered with thick dust, the packages contained multiple dead bugs and living bugs.

During an observation and concurrent interview with the RM, RS and MRIT, on 1/5/16, at 2:50 PM, of the MRI room, the shelf next to the MRI table had a white plastic bin. The bin had a dusty bottom and had multiple reddish brown stains. The bin contained a bottle of contrast liquid, (a fluid injected or taken orally to help visualize the body during an MRI), multiple open packages of four by four dressings, rolls of yellow discolored dressing tape, music buds (ear phones for patient use while in the MRI), a dime and multiple dead bugs. The MRIT stated he used the contents of the box to start patients intravenous catheters. The RS stated the contents of the bin would be disposed of. A supply storage cupboard contained a box of 25 vacutainers (used for blood draws) that expired on 2/2008 and multiple bottles of liquid contrast medium.

The hospital policy and procedure titled "Central Services", dated 6/25/14, indicated "storage shelves on nursing units are closed cabinets with clean, dry shelves so wetness, dust will not contaminate packs. Sterile supplies must be placed on clean surfaces..."

The hospital policy and procedure titled "Materials Management" dated 4/23/14, indicated
"All products with expiration dates stocked on the patient care floors will be monitored on a daily basis... Expired products should be handled immediately, disposed, returned..."

The hospital policy and procedure titled "Pest Control Process" dated 3/2015, indicated "Each department head shall ensure their departmental area is clean and pest free".

3. During an observation and concurrent review with the RM, RS, and ICN, on 1/4/16, at 10:25 AM, in Radiology Room 2, a sharps disposal container (a rigid container used to collect any discarded article that may cause punctures or cuts such as used needles, syringes) was found overfilled. Syringe packages were protruding out of container opening and available for access by any staff or patient in the room. The RM said the container would be emptied immediately.

The hospital policy and procedure titled, "Hospital Waste" dated 7/2011, indicated
Sharps are to be disposed of only in approved puncture resistant rigid containers. All disposal boxes and sharps disposal containers will be checked daily by employees. All containers must be replaced when they become 3/4 full for employee safety.

4. During an observation and concurrent interview with the RM on 1/5/16, at 12:17 PM, in the Medical-Surgical unit, a visitor was inside Patient 21's room speaking with the patient without wearing gloves or a gown. The room was a contact isolation (a type of isolation that prevents the spread of infection) room by signage on the entry door stating, "DO NOT ENTER WITHOUT STAFF ASSISTANCE, wear gloves and wear gowns". The visitor stated that she had not received information regarding isolation or gowning procedures. RNM 2 was notified and responded to educate the visitor. RNM 2 was wearing a gown that did not cover her back while speaking with the visitor. The RM stated "We need isolation education".

During this same observation, Certified Nursing Assistant (CNA) 1 was observed entering Patient 21's contact isolation room with a mobile vital signs machine (equipment cart on wheels containing a blood pressure cuff, thermometer, pulse, and oxygen monitoring equipment). Upon exit of the contact isolation room, CNA 1 was observed using Sani-Wipes (a disposable material wet with sanitizing solution used to clean surfaces and equipment to reduce transmission of infection) to clean only the reusable, cloth blood pressure cuff and cables. The cart and equipment on the cart was not cleaned before moving the equipment through the hallway.

The RM said the equipment would be cleaned immediately.

The Contact Precaution sign on Patient 21's door indicated, "Clean equipment with Hospital approved cleaner 1.(QUAT or sani wipes) 2. followed by bleach".

The hospital policy and procedure titled, "Infection Control" dated 4/2015, indicated "Dedicate the use of non critical patient-care equipment such as thermometer, stethoscope, or blood pressure to a single patient or cohort of patients infected or colonized (infection on an individual, as demonstrated by a positive culture. The infected person may have no signs or symptoms of infection while still having the potential to infect others with the pathogen requiring precautions" is contained in the hospital policy and procedure Transmission Based Precautions Airborne, Droplet, Contact, Empiric Isolation."

5. During a concurrent observation and interview with the RS and Radiology Technician (RT) 1 on 1/5/16, at 2:30 PM, of the outpatient radiology department, RT 1 was observed cleaning a patient examination table in examination Room 1. The table had a torn and cracked mattress, with the inside white mattress contents exposed, using Super Sani-Cloth germicidal disposable wipes (disposable material saturated with disinfectant). RT 1 wiped the patient table with the wipes. When asked about the kill time (required kill time listed on the U.S. Environmental Protection Agency registered label indicates the minimum amount of time the disinfectant must be in contact with the surface being disinfected), RT 1 stated, "it takes about 15 to 30 seconds to clean the table, yes that's the wet time." The RS stated she would dispose of the torn mattress since it could not be disinfected properly. The manufacturer's recommendations, printed on the germicidal container, read "Treated surface must remain visibly wet for a full two (2) minutes. Use additional wipe(s) if needed to assure continuous two (2) minute wet contact time."

During a concurrent observation and interview with the RS and the MRIT on 1/5/16 at 2:50 PM of the outpatient MRI department, the MRIT was observed cleaning a patient MRI table with a torn, cracked mattress, with the white mattress contents exposed, using Cavi-wipes germicidal disposable wipes (disposable material saturated with disinfectant). The MRIT wiped the patient table with the wipes for 30 seconds. When asked about the kill time (required kill time listed on the U.S. Environmental Protection Agency registered label indicates the minimum amount of time the disinfectant must be in contact with the surface being disinfected), the MRIT stated, "It takes about 15 to 30 seconds to clean the table, that's the wet time."

The manufacturer's recommendations printed on the container read "Treated surface must remain visibly wet for a full two (2) minutes. Use additional wipe(s) if needed to assure continuous two (2) minute wet contact time."

The RS stated she would dispose of the torn mattress and two pillows with large holes since they could not be disinfected properly and was not sure what cleaning product should be used to disinfect them.

During a concurrent observation and interview with the RS and Ultra Sound Tech (UST) on 1/5/16 at 3:20 PM of the outpatient Nuclear Medicine department, the UST was observed cleaning a patient Ultra Sound table mattress with Clorox Bleach Solution disposable wipes (disposable material saturated with disinfectant). The UST wiped the patient table with the wipes for approximately 1 minute. When asked about the kill time (required kill time listed on the U.S. Environmental Protection Agency registered label indicates the minimum amount of time the disinfectant must be in contact with the surface being disinfected), stated, "I would just leave it on till it dries." The Ultra Sound patient table had a mattress with multiple tears which were covered with patient care tape. The RS stated staff should never use tape on a mattress, and she would dispose of the mattress.

The manufacturer's recommendations printed on the Clorox container read, "Treated surface must remain visibly wet for a full four (4) minutes. Use additional wipe(s) if needed to assure continuous four minute wet contact time."

When asked if the hospital had printed information regarding how to use the disinfectant, the RS stated that she did not have printed information available.

During an interview with the ICN, on 1/6/16 at 12:30 PM she stated, "we use sani-wipes to clean mattresses, with a wet time of two minutes, we do not have any Cavi-wipes. Bleach wipes should only be used to clean mattresses exposed to C-Dif (infectious disease). We would get rid of any mattresses with rips. I've reviewed the process with staff so often."

The hospital policy and procedure titled "Cleaning Supplies" dated 3/2015, indicated "The facility shall insure that all cleaning supplies and chemicals used for cleaning are properly selected, used and maintained. Label directions should always be followed unless otherwise directed by the Environmental Services Director."

6. During observation and concurrent interview on 1/5/16, at 10:05 AM, in the Endoscopy clean storage room, with the RM, ICN, Operating Room Director (ORD) the endoscopes (a flexible tube with a light, and camera attached to it, to view and/or operate on internal organs and vessels of the body) were stored in an unvented wooden cabinet, that was too short to accommodate the length of the endoscopes. The endoscopes were bent toward the tips where the light and camera ports are located. The tips were in contact with the bottom of the wooden cabinet, and each one was wrapped with a piece of pink foam. The RM, ICN, and ORD verified the observations.

The Association of Perioperative Registered Nurses (AORN) Recommended Practices for Cleaning and Processing Flexible Endoscopes and Endoscopes recommendation IX states "Flexible endoscopes should be stored in a manner that protects the device from damage and minimizes contamination." Recommendation IX.a. states "Flexible endoscopes should be stored in a closed cabinet with venting that allows air circulation around the flexible endoscopes... adequate height to allow flexible endoscopes hang without touching the bottom of cabinet..." The residual fluid can pool at the tip of the endoscope and cause re-contamination of the endoscope without staff knowledge.

7. During a concurrent tour and interview with the ORD of the decontamination area of surgical services on 1/5/16 at 10:50 AM, Surgical Tech (ST) 1 demonstrated how contaminated surgical instruments were cleaned using the product Klenzyme® (a liquid, enzyme-based presoak and cleaner for surgical instruments). ST 1 stated the manufacturer's instructions for use indicated to use one ounce of product for six gallons of water in the sink. When asked how he measured the water to six gallons in the sink, he stated he did not have a means to accurately measure the amount of water. At that time the ORD stated the hospital adopted the AORN, Guidelines for Perioperative Practice as their nationally recognized guidelines for the infection control program.

According to the AORN, Perioperative Standards and Recommended Practices Guideline for Cleaning and Care of Surgical Instruments, Standard V (2015): Measuring devices are used to mix detergents at the concentration specified by the detergent manufacturer's written instructions for use.

8. During an interview with ST 1, on 1/6/16 at 10:50 AM, he stated the surgical decontamination area was cleaned at the end of each day by one of the surgical technicians. He stated that the product used for cleaning and disinfecting the floors is Quat Stat SC. He stated that the product needed to remain wet for three minutes to be effective.

According to the manufacturer's instructions, QUAT-STAT (Trademark) SC is a disinfectant that after application must remain wet for 10 minutes on the surface to ensure proper disinfection.

According to the CDC/HICPAC, Guidelines for Environmental Infection Control in Health-Care Facilities (2011), Cleaning and Disinfecting Strategies for Environmental Surfaces in Patient-Care Areas: Select EPA-registered disinfectants ...and use them in accordance with the manufacturer's instructions.

On 1/6/16 at 11:45 AM, during an observation of Patient 23's room, who was in contact isolation precautions for Clostridium difficile (a bacteria that causes diarrhea and serious inflammation and infection of the intestine). Environmental Services Technician (EST) 1 was observed cleaning the floors of Patient 23's room with a product from a bucket that was unlabeled. EST 1 walked to the housekeeping closet to identify the product that was in the cleaning bucket. She identified it as Green Earth Daily Floor Cleaner, a cleaning agent and not a hospital grade disinfectant. The ICN stated that this was not the proper product for the daily cleaning of a patient room with enhanced contact precautions.

According to the hospital policy entitled Cleaning Patient Room - Occupied, dated 6/14/15, "all occupied patient rooms will be cleaned on a daily basis ...Damp mop floor with a hospital approved germicidal (a substance or agent that kills germs, especially pathogenic microorganisms; a disinfectant) solution."

According to the Guidelines for Environmental Infection Control in Health-Care Facilities, Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC), 2003, Centers for Disease Control and Prevention (CDC), the recommended approach to environmental infection control with respect to C. difficile is meticulous cleaning followed by disinfection using hypochlorite-based germicides.

According to the AORN, Perioperative Standards and Recommended Practices, Recommended Practices for Environmental Cleaning in the Perioperative Setting (2015): Chemicals placed into a secondary container must be labeled with the chemical and the solution's concentration ....Policies and procedures for environmental cleaning and disinfection should include, but not be limited to ...labeling of secondary containers.



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