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Based on observation, staff interview, and review of manufacturer's instructions and product label information, the facility failed to use appropriate aseptic technique for 2 of 2 spinal injection observations. In addition the facility failed to recognize and enforce proper cleaning and disinfecting practices in the OR and sterile processing areas for 4 of 4 observations. The facility also failed to remove 5 containers of expired hand hygiene product from use in patient care and administrative areas. The findings were:

1. Observations of injection practices on 8/14/12 revealed the following discrepancies in aseptic technique:

a. On 8/14/12 at 12:10 PM physician #1 performed a lumbar epidural steroid injection for patient #3 and performed a similar procedure at 12:25 PM for patient #2. The physician was not observed to wear a surgical mask at any time during the procedures.

b. Review of the facility's policy #16 entitled "Lumbar Epidural Steroid Injection", effective July 2010, failed to address the use of masks use during spinal injections. Interview with RN #4 on 8/14/12 at 12:30 PM revealed that the observed procedures demonstrated the facility's usual standards of practice for spinal injection.

c. The 2011 Center for Disease Control and Prevention (CDC) guideline for safe injection practices recommends that healthcare providers performing spinal injections use practices that will not place patients at risk for life-threatening infections, such as bacterial meningitis. The guideline recommends "...facemask should always be used when injecting material or inserting a catheter into the epidural or subdural space." The CDC guideline further recommends that aseptic technique and other safe injection practices be followed for all spinal injection procedures.

d. Observation of a surgical procedure on 8/14/12 from 8:05 AM to 9:49 AM showed physician #2 failed to consistently cleanse the open ports on intravenous (IV) tubing prior to injecting medications. Subsequent observation of an endoscopy procedure on 8/15/12 from 7:40 AM to 7:48 AM showed physician #3 failed to consistently disinfect the IV port and rubber septum prior to piercing or injection throughout the procedure.

e. According to Elkin, Perry and potter, "Nursing Interventions and Clinical Skills, Administration of Injections", Chapter 17 and "Administering Intravenous Medications", Chapter 27, Fourth Edition, Mosby, Inc., 2007, intravenous ports and vial tops should be cleansed with sterile 70% isopropyl alcohol or other approved antiseptic swab. This should be done with friction and the port allowed to dry before accessing.

Similar recommendations are presented by the Association for Professionals in Infection Control and Epidemiology (APIC) as published in the American Journal of Infection Control, APIC position paper: Safe Injection, infusion, and medication vial practices in health care, April 2010, pp. 167-172. The APIC position endorses the recommendation that vials always be cleansed with sterile 70% alcohol or other appropriate product prior to accessing for patient use.

2. Observations of cleaning and disinfecting practices on 8/14/12 and 8/15/12 revealed the following deficiencies:

a. According to the label on a container of Rapicide (a high level disinfectant) test strips, the test strips have an open-vial stability of 90 days after first opening. However, observation on 8/14/12 at 8:04 AM revealed the container was not dated when first opened and failed to have a modified expiration date to accurately reflect the reduced shelf life of the opened container. Interview at that time with ST #1 confirmed the test strips were not dated when opened.

Subsequent observation on 8/14/12 at 4:23 PM showed ST #1 placed a test strip into the Rapicide and immediately read the results (a change in color). However, review of the label on the container of test strips revealed the manufacturer's instructions to "...wait exactly 75 seconds..." before interpreting test results.

b. Observation following a procedure in OR #3 on 8/15/12 at 8 AM revealed staff were cleaning and disinfecting surfaces in the room using wet cloths. Scrub tech #1 and RN #1 were observed to wipe the operating table, computers, and various tables/trays. At 8:05 AM, observation of these same surfaces revealed they were not visibly wet after 5 minutes. Room turn-over was again observed on 8/15/12 at 11:10 AM. Multiple staff in OR #1 were seen to use a chemical disinfectant on horizontal and high-touch surfaces following a surgical case. Staff wiped surfaces with disinfectant solution and the surfaces were observed to dry in less than 5 minutes following application of the disinfectant.

Interview with the OR manager on 8/14/12 at 10:06 AM revealed the staff used a chemical disinfectant " ...with the 10 minute wet time..." She acknowledged the surfaces did not remain wet for at least 10 minutes. Review of the product label for the chemical disinfectant on 8/14/12 at 10:25 AM confirmed the manufacturer's instructions required a minimum of 10 minutes continuous wet exposure to disinfect a non-porous surface.

c. Terminal cleaning of OR #4 was observed on 8/14/12 from 6:30 PM to 7:40 PM. During the 70 minute observation housekeeper #1 was seen to return a used mop cloth to the same bucket of disinfectant solution 6 times. She further returned a used cleaning cloth to the same solution 5 times while cleaning in the OR.

Interview with the OR manager on 8/14/12 at 7:10 PM revealed she was not aware the housekeeper was repeatedly returning used mop covers and cloths to the same cleaning solution. She further stated she was not aware that "double-dipping" (returning used items to a cleaning solution) was an inappropriate practice for terminal cleaning based on current AORN recommendations. The manager acknowledged the facility did not have policies and procedures specific for terminal cleaning ORs, nor were staff assessed for their competency in terminal cleaning.

The ICP acknowledged in interview on 8/14/12 at 7:20 PM that double-dipping was not an acceptable practice for terminal cleaning in the OR. She further stated the facility did not have a protocol in place to monitor the quality of terminal cleaning. The ICP further stated the facility based its OR practices, to include terminal cleaning and room turn-over, on current AORN standards.

d. Observation on 8/14/12 at 7:15 AM showed RN #2 used a glucometer to screen the blood glucose level of patient #7. Continued observation showed the RN wiped the glucometer with an alcohol pad for 36 seconds after using the device with patient #7. Review of the manufacturer's instructions and interview with the CNO on 8/14/12 at 3:55 PM revealed alcohol was not an effective disinfectant for use on a point-of-care device, such as a glucometer, when intended for use with multiple patients.

e. Observation during a surgical procedure on 8/14/12 from 8:05 AM to 9:49 AM showed the floor in OR #2 had multiple areas of wax build up making it appear visibly unclean. Interview with RN #1 on 8/14/12 at 8:40 AM verified the floor had wax build up in spots which made it look dirty and feel sticky.

3. Observation during the initial tour of the facility with the plant operations manager on 8/13/12 from 4:10 PM until 5:45 PM uncovered 5 wall-mounted containers of hand hygiene product that were expired. The expired products were available for use and found in the following areas:

a. Avagard hand rub in patient room #103 expired September 2011.
b. Cal Stat Plus hand rub in the housekeeping closet expired December 2011.
c. Cal Stat Plus hand rub outside patient room #185 expired April 2012.
d. Cal Stat Plus hand rub located in the hallway outside room #168 expired April 2012.
e. Cal Stat Plus hand rub located in the Administration entrance expired December 2011.

Interview with the plant operations manager at the time of the observations confirmed the hand rub products were expired. He further acknowledged at this time that housekeeping staff were responsible for maintaining hand hygiene product in the hospital.