HospitalInspections.org

32059

Based on observation, staff interview, and policy review it was determined the facility failed to establish written infection prevention and control guidelines to reflect procedure changes for surgical instrumentation and failed to ensure a sanitary environment. This has the potential to affect all patients admitted to the Labor and Delivery unit. The active census was 857. The hospital averages approximately 4900 deliveries annually.


Findings include:


1. During tour of the Labor and Delivery unit on 11/18/19 AM at 11:30 AM an interview was conducted with Staff O who reported the unit has a new cleaning procedure following vaginal deliveries. A request was made for written documentation of the change in process and/or procedure related to vaginal deliveries and instrument handling.

On 11/19/19 an email was provided by Staff M regarding mandatory education for all staff regarding sterile technique and the new instrument process. The information was sent to all labor and delivery staff in a mass email on 10/24/19 with the following information:

1). Operating room instruments process: we need to remove the EZ foam from use and replace with Pre-Klenz. (pre-soak gel for surgical instruments) The instruments will be taken out of the water basin and placed in the casket, sprayed with Pre-Klenz, covered with a wet towel, the lid placed on casket, biohazard tag placed on casket, and taken directly to the case cart.

2). Vaginal instruments will be taken out of the water basin and placed in the casket, sprayed with Pre-Klenz, covered with a wet towel, the lid placed on casket, biohazard tag placed on casket, and taken directly to the case cart. The water from the basin will be flushed down the toilet.

a). Vaginal instruments should not be rinsed in patient sinks
b). Do not pour body fluids down the sink
c). Discontinue use of green detergent immediately
d). No instruments should go to placenta room and should go directly to the case cart

Laryngoscope blades: send blades down as other instruments in red bin. Remove gross soil with wet cloth or 4 x 4; spray with Pre-Klenz; place moist towel; take to case cart.

Personal Protective Equipment: In both operating room and vaginal deliveries, wear appropriate personal protective equipment per directive.

Education and training was provided to staff on 10/28/19 and 10/29/19 to ensure the transition.

Review of the Policy and Procedure for Point of Use and Decontamination of Instrumentation lacked the guidelines contained in the mass email sent to staff. It was reported this was a hospital wide policy and is not specific to the Women/Infant and Labor and Delivery units. On 11/21/19 a request was made for the infection control policies specific to the Women/Infant and Labor and Delivery units. An overview was provided in which staff are to adhere to the standards of infection prevention and control. The document outlined details related to the practice of infection prevention and control specific to the unit. The overview also lacked evidence of the guidelines and/or the expectations of all staff to regarding the new infection control practices.

An interview was conducted with Staff K & P on 11/21/19 at 12:58 PM who confirmed there is no written instructions for staff regarding the expectations for deliveries and instrumentation. This change in process was provided to staff during the training sessions. It remained unclear of how newly hired staff and contracted staff would receive this change in process and/or procedure related to infection prevention and control. Staff P reported this information would become a part of training upon hire however these guidelines are not currently in the orientation packet.

2. The facility's Labor and Delivery, High Risk Antepartum, and Postpartum units were toured on 11/18/19 at approximately 11:00 AM. Three Recovery rooms were noted in a hallway, outside of the Operating Rooms (ORs). Although one of the Recovery rooms was occupied, two rooms, Recovery room #2 and Recovery room #3, were vacant. The top of the monitor affixed to the wall in Recovery room #3 was covered with dust and large clumps of dust were observed to fall to the floor. Dust was also noted on the monitor in Recovery room #2.

A portable monitor used for newborns during resuscitation was noted in the hall outside of the Recovery rooms. A thick layer of dust was noted on top of the monitor.

Labor and delivery room (LDR) room #610 had a white residue noted on the stirrups attached to the bed. Areas of peeling paint and rust were also noted on the stirrup handles that allow the stirrups to move.

An Environmental Services (EVS) staff member E was observed to be exiting LDR #664 carrying a mop. Staff E stated that the room was clean and ready for use. Reddish-brown stains resembling Betadine solution were noted on both stirrups attached to the bed. Peeling paint and rusty areas were noted on the moveable arms of the stirrups. A thick layer of dust was noted on top of the infant warmer in the room and clumps of dust were noted to fall to the floor.

A labor bed was noted in the hallway outside of LDR room #690. Staff O, present during the tour, stated labor beds are sometimes moved from LDR rooms and replaced with "more comfortable" beds when patients that have delivered are required to remain in Labor and Delivery. The stirrups on this bed were noted to have thinning areas of vinyl that exposed the cushion. Areas of rust and paint were also noted on the mechanism of the stirrups.

One of three ORs was toured. A thick layer of dust was noted on top of the monitor above the surgical bed. Dust was also noted on top of a clear tackle box that was labeled "Emergency Use." A large area of adhesive residue was noted on the "candy cane" leg stirrups. A blood warmer with a sticker that was peeling off revealed a brown sticky residue underneath and a white residue on top.

Outside of the OR suites, in the hallway, was an emergency airway cart. Staff O revealed the cart was primarily used for difficult intubations. The top of the cart was covered with a thick film of dust. A pair of stirrups were also noted to be resting against the wall of the OR corridor. The vinyl of the stirrups was noted to be torn exposing the cushion. Staff O revealed the stirrups were used for bariatric patients.

Postpartum room #748 was also toured. Exposed cushion was noted in areas where the vinyl was ripped on the sleep sofa.

A portable monitor was noted in the Postpartum hallway. A layer of dust was noted on top of the monitor.

3. The facility policy titled "Cleaning and Low Level Disinfection" (Policy Number:01-18), issued 3/2011, was reviewed on 11/19/19 at 10:45 AM. According to the policy, staff within the Departments of Nursing, Pharmacy, Pharmacy, Respiratory Therapy, Radiology and others is responsible for cleaning and disinfecting medical equipment and devices used within their scope of practice. Nursing cleans and disinfects medical equipment used by nursing staff. Individual unit managers may work with EVS and other departmental directors to negotiate cleaning and disinfection responsibilities and assignments. Prior to cleaning non-critical patient care items, staff are instructed to inspect surfaces for breaks in integrity that would interfere with cleaning or disinfection. Any item that no longer functions as intended or cannot be properly cleaned and disinfected should be discarded or sent out for repair.

Staff O was interviewed during the tour on 11/18/19. Staff 0 revealed although the facility policy states, nursing staff are responsible for cleaning equipment found to have dust, Labor and Delivery management delegated the cleaning of equipment to the Patient Services Associate (PSA). Staff O stated, however, that Labor and Delivery had been without a PSA "for several months." It was confirmed there was no documentation of an attempt to delegate the cleaning of equipment to a staff member to ensure the cleanliness of the unit. It was further confirmed there was no documentation of equipment that could not be properly cleaned being discarded or sent out for repair.