HospitalInspections.org

The Critical Access Hospital (CAH) reported a census of six patients. Based on observation, policy review, manufacturer's guidelines, and staff interviews the infection control officer failed to develop an active and comprehensive infection control system which identified and investigated concerns for one of one observed cleaning of a discharged patient room and one of one terminal cleaning of the operating room.

Findings included:

- The CAH's job description reviewed on 9/12/13 at 11:00am for the Infection Control Officer directed "...She/He is responsible for the identification, investigation, reporting, prevention, and control of healthcare associated infections among patients, and personnel..."

- Infection Control Officer staff D interviewed on 9/12/13 at 9:00am verified they were responsible for the management of the infection control program. Staff D acknowledged they did not have a formal surveillance program with criteria for staff and environmental practices observing breaches in infection control.

- The manufacturer's guidelines for "Beaucoup Germicidal Detergent" cleaner reviewed on 9/12/13 at 9:15am directed for disinfection "...contact time (wet) for 10 minutes..."

- Staff P on 9/10/13 between 3:12pm and 3/40pm cleaned operating room #1 of the surgical suite. Observation revealed the following breaches in infection control practices regarding disinfectant wet time per manufacturer's recommendation for total disinfection. For example:

Staff P using "Beaucoup Germicidal Detergent" cleaner cleaned the patient table and base, Mayo stand, metal back-up table, bedside table, arm board, prep table, and floor. The surfaces remained wet between three to eight minutes. The surfaces failed to remain wet for the required 10 minutes for total disinfection.

Staff P interviewed on 9/10/13 at 3:40pm acknowledged the surfaces failed to remain wet the required 10 minutes for total disinfection.

- Review of the manufacturer's guidelines on 9/11/13 at 11:30am for "Virex 256 One-Step Disinfectant Cleaner and Deodorant" directed, "To disinfect hard, non-porous surfaces, treated surfaces must remain wet for 10 minutes."

- Review of the manufacturer's guidelines on 9/11/13 at 11:30am for "Lysol Basin tub and tile Cleaner" directed, "...Spray surfaces until thoroughly wet...to disinfect leave for 10 minutes before wiping..."

- Review of the manufacturer's guidelines on 9/11/13 at 11:30am for "SparCling one-step cleaner/disinfectant" directed, "...disinfecting Toilet Bowls and Urinals, ...remove water from bowl...apply 1-2 oz. of SparCling evenly onto surfaces...swab entire surfaces... allow SparCling to remain wet on surface at least 2 minutes..."

- Observation of staff A housekeeping supervisor and staff B a housekeeper, on 9/10/13 between 1:50pm to 2:25pm revealed cleaned a discharged Obstetric patient's room, room 203. Observation revealed the following breaches in infection control practices regarding disinfectant wet time per the manufacturer's recommendations for total disinfection.
For example:

Staff A and B wiped the basinet, sofa, sink, counter, bed side table, and pillows with cleaning cloths wet with a solution of "Virex 256" disinfectant. The surfaces remained wet between two to five minutes. The surfaces failed to remain wet for the required 10 minutes for total disinfection.

Staff A using "Lysol Tub and Tile cleaner" sprayed the inside of the Jacuzzi tub and jet filters. The surfaces remained wet for three minutes before Staff A sprayed the inside of the tub and jet filters with water. The surfaces failed to remain wet for the required 10 minutes for total disinfection.

Staff A using "SparCling" toilet bowl disinfectant poured one ounce in the toilet, swabbed the toilet with a toilet bowl mop and flushed the toilet. Staff A failed to remove the water from the toilet bowl and leave the "SparCling" on the surfaces of the toilet bowl for two minutes. The failure to follow the manufacturer's recommendations resulted in resulted in a failure to reach total disinfection.

Staff B using "Neutral Cleaner" (not a disinfectant) wiped the floor with a micro fiber mop and let it dry per the manufacturer's recommendations. The CAH failed to use a disinfecting product on the floor when conducting a terminal clean of a discharged patient's room.

Staff A interviewed on 9/10/13 at 2:35pm acknowledged the surfaces failed to remain wet the required 10 minutes for total disinfection and failed to follow the manufacturer's recommendations for the use of the SparCling toilet bowl disinfectant. Staff A acknowledged the "Neutral Cleaner" was not a disinfectant.