HospitalInspections.org

Based on observation, interview, and record review the facility failed to do the following which may lead to the spread of infection.

1. Clean an ice machine daily as scheduled.
2. Prepare a tray of surgical instruments for sterilization as the facility's policy and procedure requires.
3. Ensure a sharps container in a patient's room was emptied according to facility policy.

Findings:

1.During an observation on 5/14/2024 at 2:15 PM, in a supply room in the SPD (Sterile Processing Department, area where surgical/procedural instruments are cleaned/sterilized), there was an ice machine at the back of the room. On the left side of the ice attached to the machine was a daily cleaning checklist (log of daily routine cleaning of the machine). The latest documentation of daily cleaning of the machine was 5/10/2024; All the previous dates on the log were signed, acknowledging the ice machine had been cleaned. There was a slight cover of dust on the top of the machine.

During an interview on 5/14/2024 at 2:15 PM, the Nurse Surgery Manager stated the ice machine should be cleaned daily so that frequent handling of the machine does not pass to the ice and increase possibility of transmission of infection.

During a record review of the Policy/Procedure 'Ice Machine Cleaning' (last revised 8/2023), this document indicated the procedure for maintaining infection control for ice machines throughout the facility. This procedure included: using a hospital approved cleaning agent to wipe down exterior surfaces of the machine; clean cleaning clothes, using hospital approved cleaner, reach inside the spout (chute through which ice is dispensed) as far as possible to disinfect; on a weekly basis use line cleaning agent to remove mineral buildup; dust the top of the machine weekly.

2. During an observation in the SPD on 5/14/2024 at 2:18 PM, accompanied by the Nurse Surgery Manager, there was a 'minor tray' (tray of surgical instruments used during minor surgical procedures that includes scissors, scalpels, forceps etc.) that the Nurse Surgery Manager opened. Among the instruments were 69 forceps (used to grasp, retract, or stabilize tissue and similar in appearance to scissors). These 69 forceps were mounted on a metal stringer (rod through the handles of the forceps whose purpose is to separate the jaws of these instruments). Of the 69 forceps, 19 of them were in the jaws closed position.

During an interview in the SPD on 5/14/2024 at 2:18 PM, the Nurse Surgery Manager acknowledged that all these instruments should be in the jaws open position so steam can reach all surfaces during the sterilization process.

During a review of the policy 'Instrument Cleaning and Processing' (last reviewed 12/2021), this policy indicated professional guidelines published by AORN (Association of Operating Room Nurses) and AAMI (Association for the Advancement of Medical Instrumentation) are used during the process of sterilizing surgical instruments.

During a review of the AAMI standards for steam sterilization (ANSI/AAMI ST79:2017), supplied by the IP on 5/14/2024 at 3:45 PM, this document indicated load configurations (how instruments are positioned in the sterilizer) 'should ensure adequate air removal, penetration of steam into each package, and steam evacuation'. This document specifies perforated trays or rigid sterilization sets should be placed in a horizontal position in order to prevent shifting of the set, penetration of the sterilant (steam), drainage of condensate, and drying evacuation.

3. During an observation on 5/14/2024 at 12:45 PM, in patient room 2432 accompanied by the IP, there was a sharps container (specially designed containers into which used needles and other medical-waste sharps are discarded) on the far wall of the room. The container was full and a used syringe protruded from the top.

During an interview on 5/14/2024 at 12:45 PM, the IP stated that sharps containers should be emptied when about three quarters full as she noted the used syringe from the top of the container.

During a record review of the policy '[Regional] Sharps and Needle Handling and Disposal' (last reviewed 9/2021), this document indicated devices such used needles, lancets, scapels should be disposed using a sharps container immediately after use. This policy stated in order to prevent personal injury or theft and abuse of sharps, containers are to be closed and changed when they are 2/3 to 3/4 full.