HospitalInspections.org

Based on observation, record review, and interview, the Hospital failed to maintain a system for controlling sources of infections in accordance with hospital policies and procedures, nationally recognized infection control practices and guidelines, and applicable regulations when:

1. Hand Hygiene was not performed in accordance with Hospital policy and nationally recognized infection control guidelines.
2. The continued need for urinary catheters was not evaluated on a daily basis in accordance with Hospital policy.
3. The continued need for central line catheters was not evaluated on a daily basis in accordance with Hospital policy.
4. Manufacturer's disinfecting wet contact time was not met during cleaning.

These failures had the potential to spread infection to the hospital's patients, staff, and visitors.

Findings:

1. During an observation of the operating room on 1/5/15 at 1:40 PM, Registered Nurse (RN) A was performing in the role of circulating nurse and was observed preparing medications for the sterile field (a specified area that is considered free of microorganisms). In between preparing multiple medications to be added to the sterile field, he handled the inside cover of the trash receptacle three times with ungloved hands and did not perform hand hygiene, three out of three times, before resuming his task of medication preparation.

During an observation of discharge cleaning in Room 225, on 1/6/15, at 10:40 AM, Environmental Services Staff (EVS) A changed gloves, which were used for cleaning the patient environment, three times. She was observed to perform hand hygiene during one of the three glove changes instead of after each glove change.

The hospital policy and procedure titled "Hand Hygiene" dated 5/23/13, indicated hand hygiene was to be performed "before clean/aseptic procedures,... after contact with the patient environment and... immediately before putting on gloves and immediately after removing them." The reference for the policy included the Centers for Disease Prevention and Control (CDC) and the World Health Organization (WHO).

2. During a concurrent interview with RN C and the Infection Control Practitioner (ICP) and review of the clinical records for Patient 10 and 13, on 1/5/14 at 3 PM, RN C and the ICP acknowledged that Patient 10 and Patient 13 had urinary catheters (a tube placed into the bladder that drains urine into a bag) in place. They further acknowledged there was no daily documentation in the clinical records which identified the ongoing need for the urinary catheters for Patient 10 and Patient 13.

The Hospital policy and procedure titled 'Urinary Catheterization" dated 8/28/14 indicated a daily review of the continuing need for the urinary catheter was to be performed by the physician and registered nurses.

3. During a concurrent interview with RN C and the ICP and review of the clinical record for Patient 10 on 1/5/15 at 3 PM, RN C and the ICP acknowledged that Patient 10 had a central line (a catheter or tube placed into the vein in order to provide fluids and medications). They further acknowledged there was no daily documentation in the clinical record that identified the ongoing need for the central line in Patient B.

The hospital policy and procedure titled "Prevention of Central Line-Associated Bloodstream Infections (CLABSI)" dated 8/28/14, indicated a daily assessment was to be completed for the continued need for intravascular access and to remove catheters not required for patient care.

4. During an interview with the ICP and RN B on 1/5/15 at 9:50 AM, they both stated the Hospital followed the Association of periOperative Registered Nurses (AORN) nationally recognized infection control guidelines.

During an observation of discharge cleaning in Room 225 on 1/6/15 at 10:40 AM, EVS A applied A-456 II (a disinfectant) to furnishings in the room. After two minutes, the bedside table and the chair were observed to be completely dry. At this time, EVS A stated the dwell time or wet contact time (time required for the disinfectant to remain wet in order to kill micro-organisms) for A-456 II was 10 minutes.

During an interview with the EVS Supervisor on 1/6/15 at 2:15 PM, he confirmed the required time for wet contact time for A-456 II was 10 minutes.

The manufacturer's instructions for A-456 II indicated the disinfectant was to be "applied to hard, nonporous surfaces, thoroughly wetting surfaces with a cloth... Treated surface must remain wet for 10 minutes. Wipe dry with a cloth, sponge or mop or allow to air dry."

The AORN publication titled "Perioperative Standards and Recommended Practices, Recommended Practices for Environmental Cleaning" dated 2014, read "Recommendation II: The patient should be provided with a clean, safe environment: Disinfectants should be applied and re-applied as needed, per manufacturers' instructions, for the dwell time required to kill the targeted microorganism."

The CDC publication titled "Guidelines for Environmental Infection Control in Health-Care Facilities" dated 2011, under Cleaning and Disinfecting Strategies for Environmental Surfaces in Patient-Care Areas indicated to use disinfectants in accordance with the manufacturer's instructions.



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