HospitalInspections.org

The Critical Access Hospital (CAH) reported a census of three acute and swing bed patients. Based on observation, document review, and staff interview, the infection control officer failed to develop an active infection control system to identify, report, investigate, monitor, and implement infection control practices for storage of three of three endoscopes (instrument used to examine body cavities).

Findings include:

- The CAH ' s policy " Endoscopes, Use and Care Of " reviewed on 8/21/13 at 2:00 pm revealed " ...vertically stored in a protective area, stored in a manner where they will be protected from accidental contamination ... "

- Observation of dirty processing room (where surgical human waste is discarded and soiled surgical instruments are initially cleaned) on 8/21/13 at 9:30am revealed a sink and counter area used to scrub and remove tissue and debris off of surgical instruments prior to sterilization; and a hopper used to dispose of surgical human waste. Further observation revealed the CAH stored patient endoscopes, uncovered, between the two contaminated areas 9-10 inches from the contaminated sink and staff indicated the scopes were clean and ready for patient use.

- Staff C, scope processor, interviewed on 8/21/13 explained the stored scopes were clean and ready for patient use.

- Staff B, charge nurse of surgery interviewed on 8/21/13 at 9:50am acknowledged the CAH failed to store the endoscopes in a manner to ensure protection from accidental contamination.