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435 LEWIS AVENUE

MERIDEN, CT 06450

INFECTION CONTROL PROFESSIONAL

Tag No.: A0748

Based on observation the facility failed to ensure that appropriate infection control techniques were utilized. The finding includes the following:

Observation on 8/23/12 at 10:15 AM identified a phlebotomist with gloves on in a patent room drawing blood. The phlebotomist completed the task, placed the blood tube in his/her travel cart, moved the cart, then removed his/her gloves. The phlebotomist then washed his/her hands and with clean hands proceeded to push the cart out of the room. The phlebotomist failed to remove his/her gloves and wash hands prior to touching the phlebotomy cart. Review of the incident on 8/23/12 with the Infection Control Practitioner indicated that the phlebotomist should have removed his/her gloves and washed hands prior to touching the cart.

INFECTION CONTROL PROGRAM

Tag No.: A0749

1. Based on observation, interview and review of hospital policy, the hospital failed to ensure that the interventional radiology room was piped to receive appropriate air exchanges and/or that the operating room/central sterile room door was kept closed to ensure adequate air exchanges were received. The findings include:
a. During interview on 8/21/12, the Director of Facility Management stated that the hospital followed the recommendation of the American Institute of Architects (AIA) for ventilation requirements for the minimum total air exchanges per hour for the corresponding area. The Director stated that although the interventional radiology procedure room (utilized for invasive procedures) was new two years ago, the ventilation requirement had been overlooked at that time and was just now having the appropriate connections outfitted to achieve the required air exchanges.
b. During tour of the operating suite on 8/21/12 at approximately 10:30 AM, OR #4, which was cleaned and ready for the next surgical procedure, was observed to have the door to the room in an open position, therefore interfering with the appropriate air exchanges for the surgical environment. During interview on 8/21/12, the Charge Nurse stated it was an oversight following the cleaning of the room and the door should have been shut.
c. During tour of the Central Sterile Department on 8/21/12, at approximately 11:30 AM, observation was made that the main door to the Central Sterile Department was propped open. Upon questioning as to why the door would be propped open, the door was closed. During interview on 8/21/12 at approximately 11:35 AM, the Infection Control Practitioner stated that the door should always remain closed to the department. According to the AIA ventilation requirements, the Central Sterile Department should receive between 4-10 air exchanges per hour.

2. Based on observation, interview and review of hospital policy, the hospital failed to ensure that the disinfectant utilized in the operating room for cleaning between patients was utilized in accordance with the manufacturer's directions. The finding includes:
During observation of the cleaning of an operating room (#1) on 8/21/12 at 10:22 AM, it was observed that CAVI wipe cleaning cloths were utilized for cleaning all surfaces, including the operating table. It was observed that when the table mattress was wiped, although the wipe was wet, the cleaning process did not leave the surface wet for two full minutes according to the manufacturer's directions for the cleaning solution utilized. Review of the hospital policies for environmental cleaning in the OR identified a failure to stipulate timely cleaning of the OR table and/or directive to follow manufacturer's instructions to achieve an appropriate level of disinfection. During interview on 8/21/12 at approximately 10:30 AM, the Infection Control Nursing Practitioner stated that she/he would expect that the surface would remain wet for the full two minutes according to the manufacturer's directions to achieve optimal bacteriocidal effect.

3. Based on observation, policy review and interview, the hospital failed to ensure that hair was covered in its entirety according to hospital policy and/or that aseptic hand washing soap was not expired. The findings include:
a. During tour of the operating suite and cesarean section rooms on 8/21/12 and 8/23/12, respectively, it was observed that numerous staff members failed to have their entire head of hair and/or facial hair/sideburns covered as they worked over the operative site. Review of the hospital policy for surgical attire directed that all hair would be covered with a cap or hood, however, the policy failed to address the coverage of facial hair.



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4. Based on observation and review of the facility policy, the facility failed to ensure that appropriate infection control techniques were utilized. The findings include the following:

a. Observations on 8/22/12 and 8/23/12 at 10:10 AM and 9:30 AM, respectively, identified the environmental service staff person doing daily cleaning. Observation of the daily room cleaning failed to identify that the bed siderails, telephone and call light device had been cleansed. Review of the facility policy for Daily Cleaning identified that doors, sinks, wall, window sill, chairs, bedside table, phone and over bed table should be cleaned daily.

b. Observation on 8/22/12 at 10:45 AM identified a patient being ambulated, returning to his/her room and then having an oxygen saturation obtained. Upon completion, the oxygen saturation machine was returned to the hallway without the benefit of being cleaned. Interview with the Infection Control Practitioner indicated that the nursing and/or respiratory departments do not have a policy for cleaning of the oxygen saturation machine.

c. Observation on 8/22/12 at 10:00 AM identified RT#1 providing a respiratory treatment via a mask. Observation identified that upon completion of the treatment the device was placed back in the respiratory bag at the bedside without being rinsed out.

d. Observation on 8/23/12 at 10:45 AM identified RT#2 providing a respiratory treatment via a mask. Observation identified that upon completion of the treatment the device was placed back in the respiratory bag at the bedside without being rinsed out. Review of the Nebulizer treatment policy identified that following the treatment the nebulizer cup, mouthpiece and/or mask should be placed in the patient set-up bag (without being washed with saline). Interview with the Manager of Respiratory on 8/23/12 at 3:00 PM indicated that washing out the device is not part of the hospital procedure.

e. Observation of a patient room on 8/23/12 at 11:30 AM, identified that the patient in the room was on enteric and contact precautions. Visitors were observed in the room without the benefit of personal protective equipment (PPE). Interview with Infection Prevention staff indicated that the facility did not have a policy that addresses the use of PPE for visitors.