HospitalInspections.org

41743

Based on observation, interview, record review and facility policy review, the hospital staff failed to follow policies and standard precautions to prevent spread of infectious disease regarding injection of medications, hand hygiene, Personal Protective Equipment (PPE) use and manual cleaning for sterile equipment and endoscopes.

Findings include:

1. Observation on 08/01/2024 at 10:10 AM of the medical surgical unit showed Registered Nurse (RN) #4 administer heparin 5000 units Subcutaneous (SQ) injection for Patient #3 in room 306. RN #4 failed to sanitize the heparin vial septum, prior to puncturing with the needle, perform hand hygiene and don clean gloves prior to touching patient and administering injection in the left lower quadrant.

Observation on 08/01/2024 at 10:25 AM of the medical surgical unit showed RN #4 administer Morphine Sulfate 4 mg via intravenous heparin lock in left upper extremity for Patient #4 in room 323. RN #4 failed to perform hand hygiene when entering the patient room, sanitize the heparin vial septum, prior to puncturing with the needle, perform hand hygiene and don clean gloves prior to touching patient and administering the medication. RN #4 also failed to sanitize the hub of the heparin lock with alcohol prior to administering sterile saline flush, prior to administering the IV push medication, prior to administering saline flush, and/or perform hand hygiene when leaving the patient room.

Review of facility policy for IV and SQ medication administration showed that the hospital and does not have a specific policy. During an interview on 08/02/24 at 2:00 PM, the Director of Quality Infection Control reports the hospital follows Lippincott recommendations.

Review of "Lippincott Procedures Subcutaneous Injections ...IV Bolus Injections" showed for IV bolus medications, staff should perform hand hygiene and don gloves to comply with standard precautions. Staff should perform a vigorous mechanical scrub of the injection port with alcohol for at least 5 seconds and allow the hub to dry completely. Subcutaneous injections do not require gloves for injection unless the patient's skin is not intact.

Review of facility policy, entitled "Single-dose & (and) Multi-dose Containers of Medication Policy IPC 01.03" showed that staff are to disinfect the septum of multi-dose medication vials with alcohol or other antiseptic swab prior to puncture.

2. Observations of the Progressive Care Unit (PCU) on 08/01/24 at 10:25 AM revealed a surgical mask, which was shaped as if it had been used, hanging on the hallway doorknob of Room 519. There was a sign on the room door that indicated "Contact Precautions." On 08/01/24 at 10:35 AM further observation revealed an N95 mask, which was shaped as if it had been used, hanging on the hallway doorknob of Room 517. A sign on the room door indicated, "Airborne Precautions." In an interview with Certified Nurse Assistant (CNA) #1 on 08/01/24 at 10:35 AM, she/he stated the patient in Room 519 "has an airborne respiratory virus," and she/he used the surgical mask hanging on the doorknob and she/he hung it there so she/he could use it again. CNA #1 stated the patient in Room 517 "has Covid so we have to wear a mask." CNA #1 confirmed she/he used the mask and hung it on the doorknob so she/he could use it again. In an interview with Registered Nurse (RN) #1 on 08/01/24 at 11:10 AM, she/he stated used masks should not be hung on the patient's room doorknobs. In an interview with the Quality Improvement Manager (QIM) on 08/02/24 at 1:15 PM, when asked if it is ok for staff to hang used surgical or N95 masks on patient room doorknobs, she/he stated, "No." The QIM stated used masks should be disposed of.

3. Observation on 08/01/24 at 11:45 AM of the Endoscopy Disinfection area showed Certified Surgical Processing Technician (CSPT) #2 cleaning endoscopy scopes using water and detergent already sitting in the sink prior to endoscopy scope being brought into the area. Once the scope was cleaned and placed in the Medivator washer, CSPT #2 drained the water, cleaned the sink with wipes and immediately refilled the sink and used the Scope Buddy to add preset amount of Enzymatic Detergent. CSPT #2 did not allow the sink to dry and this Surveyor asked why the sink was immediately refilled, CSPT #2 replied "time is money". During an interview on 08/02/24 in the first floor administration conference room, the Surgery Manager stated that the sink should be left to dry per policy.

Record review of facility policy entitled "Decontamination of reusable supplies, 4.0" showed that facility staff are to manually wash contaminated equipment using tepid water and detergent/enzymatic cleaner following manufacturer's guidelines.


4. Observation of the medical surgical unit on 08/01/24 at 1:53 PM revealed Housekeeping Staff (HS) #2 cleaning room 419 and in a concurrent interview HS #2 confirmed the patient was discharged. HS #2 applied clean gloves and emptied the trash in the room into a larger trash bag, removed the IV bag and tubing, placed it in the trash bag, removed the soiled linens from the bed, placed them in a plastic bag, and then with the same gloves on, picked up the meal tray and walked out of the patient room, down the hall and to the soiled utility room where she/he placed the meal tray. HS #2 did not remove the soiled gloves and/or perform hand hygiene before leaving the patient room. In an interview with HS #2 on 08/01/24 at 1:31 PM, she/he confirmed leaving the patient room with soiled gloves on and carrying the meal tray to the soiled utility room. In an interview with the Quality Improvement Manager (QIM) on 08/02/24 at 1:42 PM, he/she stated when housekeeping staff clean a patient room and remove soiled linens, they should remove the soiled gloves and perform hand hygiene before leaving the patient room.

Observation of Registered Nurse (RN) #3 on 08/01/24 at 2:47 PM revealed RN #3 obtaining a 1 ml (milliter) vial of medication and a syringe from the medication room and going to Room 407 on the medical surgical unit. RN #3 reached into her/his pocket and got a pen at which time a Carpujet (holds prefilled syringes) fell on the floor. RN #3 picked up the Carpujet and placed it on the counter. RN #3 did not perform hand hygiene and opened the vial of medication, popped the cap, and inserted the needle of the syringe into the vial. RN #3 did not disinfect the septum of the vial prior to inserting the needle. In an interview with RN #3 on 08/01/24 at 2:57 PM she/he confirmed she/he did not disinfect the septum of the vial after opening it. RN #3 also confirmed she/he did not perform hand hygiene after getting the pen out of her/his pocket and picking the Carpujet up off of the floor. In an interview with the Quality Improvement Manager (QIM) on 08/02/24 at 1:44 PM she/he stated if a nurse drops something on the floor and picks it up, she/he is supposed to perform hand hygiene before drawing up medication into a syringe. In an interview with the QIM on 08/02/24 at 2:05 PM she/he confirmed the hospital policy was to disinfect the septum of a vial after removing the cap and before inserting a needle to draw up medication into a syringe.

Observation of the Endoscopy Disinfection Room on 08/02/24 at 9:45 AM revealed CSPT#5 filled the washing sink with water to the level of a green line. CSPT #5 was observed cleaning an endoscopy scope and then emptying the sink. At 10:12 AM on 08/02/24, CSPT #5 filled the sink with water to the green line measuring the water as she/he filled it. The Assistant Surgery Manager (ASM) was present also. The amount of water in the sink to the white dots located in the middle of the green line was 10 ¾ gallons of water. In a concurrent interview, CSPT #5 stated she/he normally filled the sink to the white dots located in the middle of the green line. CSPT #5 was then observed pushing the button on the Scope Buddy to dispense enzymatic detergent into a measuring container which she/he stated was the amount she/he used in each sink of water to the white dots located in the middle of the green line which measured to just under 100 milliliters. The ASM obtained a smaller container to obtain a more accurate measurement and CSPT #5 poured the enzymatic detergent into the smaller container which measured out to be ASM stated, "It's 80 (ml)." Observation of the container verified it was 80 milliliters of enzymatic detergent. Review of the Olympus instructions for use (IFU's) provided by the Surgery Manager for the Scope Buddy on 08/02/24 at 3:30 PM revealed, " ...Follow the instructions provided by the detergent manufacturer regarding concentration ...". On 08/02/24 at 3:45 PM, review of the label on the enzymatic detergent used in the endoscopy cleaning room Scope Buddy revealed, " ...DIRECTIONS FOR USE [DFU] ...For Manual Cleaning of Flexible Endoscopes ...Mix enzymatic Detergent at 1 U.S. fl. Oz per U.S.gallon (7-8 ml/L) of water..". Ten ounces of enzymatic detergent should have been used per 10 gallons of water, but the hospital was using 2.7 oz of enzymatic detergent per 10 ¾ gallons of water (at least seven ounces less than the manufacturer's DFU).

Record review of manufacturer's guidelines for Enzymatic cleaner showed that staff should use 1 fluid ounce per 1 gallon of water when manually cleaning flexible endoscopes.