HospitalInspections.org

Based on observation, records reviewed and interview the Hospital failed to consistently adhere to Infection Control standards related to use of scrub sinks and the reprocessing of a single use cleaning brush.

1. The Surveyor interviewed Infection Preventionist #2 at 10:00 A.M. on 3/20/17. Infection Preventionist #2 said she had been involved in the investigation of a cluster of post-operative infections. Infection Preventionist #2 said she had identified a practice improvement during her clinical observations in the Operating Room. The Infection Preventionist said a prior practice in the Operating Room was, at the close of the cardiac surgery case, to dispose of the used reservoir waters from the Heater Cooler Unit (a machine used to maintain the patient's temperature during surgery) into the scrub sink.

The Internal Investigation of the post-operative infections indicated that on 11/28/16 the corrective action for the reservoir water was to be discarded into a soiled sink/drain.

The Surveyor interviewed the Perfusionist at 8:45 A.M. on 3/21/17. The Perfusionist said that, after the cardiac surgical case was done, he disposed of the reservoir water into the scrub sink. Scrub sinks must be dedicated to either hand washing or the surgical scrub.

The Surveyor re-interviewed Infection Preventionist #2 at 11:50 A.M. on 3/31/17. Infection Preventionist #2 said she had spoken with the Perfusionist and there had been a misunderstanding about ending the practice.

2. The Surveyor interviewed the Anesthesia Technician at 8:30 A.M. on 3/21/17. The Anesthesia Technician said she reprocessed equipment from the Operating Room. The Anesthesia Technician said she used the Medivator (an automated endoscopic reprocessor used to high level disinfect equipment between patients). The Anesthesia Technician said she used a cleaning brush to remove debris from the channels of any equipment before placing it into the automated endoscopic reprocessor. The Anesthesia Technician said she also placed the cleaning brush into the automated endoscopic reprocessor to reprocess the cleaning brush between uses.

The Surveyor requested the cleaning brush manufacturer's directions for use to ensure correct reprocessing. The Anesthesia Supply and Purchase Technician was able to locate a new brush in the original packaging but there was no reprocessing information included on the package and none in the packing box.

An online search indicated the product was a single use item and could not be reprocessed.