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Based on observation, policy review and staff interview the hospital failed to ensure expired medications were unavailable for patient use in the anesthesia block cart in the preoperative area, in the anesthesia cart in Operating Room Four (OR 4), in one of eight crash carts (Preoperative area) and in the Pyxis system (an automated medication dispensing system) in the intensive care unit. Failure to ensure expired medications are removed and unavailable for patient use places all patients at risk for receiving medications that have lost potency, that are ineffective for their intended use and that have potentially compromised sterility posing a risk for infection.

Findings Include:

Review on 09/11/18 of policy titled, "Discarding of Sterile Medication Containers," revised 03/2017, showed, The use of multi-dose vials (MDV) should be restricted, with a preference for the stocking of SINGLE-USE VIALS WHENEVER POSSIBLE....Container type Multi-Dose Vials (contain preservative),...Use within/discard after 30 days after opening and entering the vial.

Review on 09/11/18 of policy titled, "Automated Dispensing Cabinet for Medications," revised 09/2017, showed, Monthly Procedures: Pharmacy Personnel will perform an inventory or inspection of medication in the Automated Dispensing Unit (ADU) monthly and remove all medications that will expire in less than 30 days.

Review of policy titled, "Code Blue Policy and Procedure," revised 01/2018, showed, Pharmacy Department Responsibilities: Shall provide current, in date drugs...Shall check expiration dates monthly of the crash cart drug content/IV solution as recorded on the check sheet.

Observation on 09/11/18 at 9:15 AM, the Intensive Care Unit Pyxis system showed:
- Dextrose 5% Water (D5W) (a sugar solution medication given intravenous, the main usage of this drug is to provide fluid replacement for patients who are dehydrated) one liter with an expiration date of 01/2018.

During an interview on 09/11/18 at 9:15, Staff FF, pharmacy technician, stated that the Pyxis system prints a report at the beginning of each month which identifies outdated medications within the system.

Observation on 09/10/18 at 3:45 PM, the crash cart in the preoperative outpatient surgery area showed:
- Four vials of Sodium Chloride 20 milliliter (ml) with an expiration date of 06/2018.

During an interview on 09/10/18 at 3:45 PM, Staff GG, Registered Nurse (RN), Operating Room (OR) Director stated that there was a shortage of sodium chloride and there was none available anywhere, so they left them in the cart. She stated that it was not ideal but if you have nothing else, what are you to do?

Observation on 09/11/18 at 9:58 AM, the outpatient preoperative anesthesia block cart showed:
- One 2 ml vial of Xylocaine (a numbing medication injected into the skin) 10 milligrams (mg)/ml with an expiration date of 06/2018.

During an interview on 09/11/18 at 9:58 AM, Staff MM, Certified Register Nurse Anesthetist stated that there has been a shortage of Xylocaine and it was on backorder nationwide.

Observation on 09/11/18 at 3:30 PM in the OR 4 anesthesia cart showed:
- Five vials of Atropine (a medication used to treat some types of slow heart rate and to decrease saliva production during surgery) 0.4 mg/ml, three of the vials had an expiration date of 08/2018.
- One multi dose vial of Ketamine 500 mg/10 ml (a medication used to induce sleep in patient's having surgery) opened and no date marked when it was open.

During an interview on 09/11/18 at 3:45 PM Staff GG stated that there has also been a shortage on Atropine. She stated that multi-dose vials are to be dated with the date they are opened and disposed of in 30 days of that date.

Based on observation, interview, document review and policy review the hospital failed to maintain supplies within manufacturer's end use date in the 2 North Crash cart and failed to maintain sterility of syringes and blunt end needles in three of four anesthesia carts observed in Operating Room (OR) 1, OR 2 and OR 4. The hospital's failure to ensure supplies are discarded after the expiration date and failure to maintain sterility of syringes and needles has the potential for placing all patients at risk for receiving care with ineffective and unsafe medical equipment.

Findings Include:

Document review of the hospital policy titled, "Outdates - Checking of Supplies," dated 08/2017, showed by the end of the month each department must check all patient care supplies in their department, including, shelf items, PAR cart items, and floor stock items from the pharmacy...any supply item found that would expire within-thirty days should be removed from service. The item should be returned to Materials Management.

Observation on 09/10/18 at 4:11 PM, on 2 North, showed the following expired supplies in their crash cart:
- Two adult Tracheostomy tubes 6.0 (a tube inserted through a hole in the windpipe that provides an alternative airway for breathing) expired on 06/2018
- Two adult Tracheostomy tubes 4.5 expired on 06/2018
- Two pediatric colorimetric CO2 detectors (an airway management tool that detects carbon dioxide) expired on 06/2018
- Two adult colorimetric CO2 detectors expired on 07/03/18

During an interview on 09/10/18 at 4:18 PM, Staff F, 2 North Manager, Registered Nurse (RN) verified the above listed supplies were expired.

Document review of the Association for Professionals in Infection Control (APIC) position paper: Safe Injection, ... Practices in Health Care (2016) showed: APIC strongly supports adherence to the following safe injection practices...Never store needles and syringes unwrapped because sterility cannot be ensured.

Observation on 09/11/18 between 3:30 and 4:30 PM, OR 1, OR 2 and OR 4 showed each anesthesia cart had a drawer containing the following:
- Numerous 3 milliliter (ml) syringes opened and out of the package with an opened, capped blunt end needle attached
- Numerous 5 ml syringes opened and out of the package with an opened, capped blunt end needle attached
- Numerous 10 ml syringes opened and out of the package with an opened, capped blunt end needle attached
- Numerous 20 ml syringes opened and out of the package with an opened, capped blunt end needle attached

During an interview on 09/11/18 at 3:45, Staff GG stated that the syringes and needles came from sterile packaging and have not been used. She stated that anesthesia opens the syringes and needles so that they can quickly have them available for use. Staff GG stated that there is no specific policy addressing pre-opening sterile syringes and needles. She stated that the pharmacy stocks all the medications and anesthesia stocks all other supplies in the anesthesia carts in the OR's.

During an interview on 09/12/18 at 2:15 PM Staff KK, Medical Doctor (MD), Director of Anesthesia stated that they used to keep the opened syringes on top of the anesthesia cart. He stated that there is nothing sterile about drawing up medications and he has not seen any evidence of infections from pre-opening syringes.

Based on observation, staff interview, document review, and policy review the hospital failed to ensure the infection control program minimizes the risk of transmitting infections and communicable diseases by using Immediate Use Steam Sterilization (The Association of Perioperative Registered Nurses [AORN] explains IUSS as "Flash sterilization" has traditionally been used to describe steam sterilization cycles where unwrapped medical instruments are subjected to an abbreviated steam exposure time and then used promptly after cycle completion without being stored. This is in contrast to traditional "terminal sterilization" cycles, where instruments are sterilized within containers, wrappers, or primary packaging designed to maintain the instruments' sterility and allow the devices to be stored for later use. The term "flash" arose out of the abbreviated time of exposure of the unwrapped device.) of instruments for 26 of 30 patients (Patient's 30-38 and 43-60) scheduled for cataract surgery on 08/08/18, 08/29/18 and 09/12/18. The cumulative effect of the hospital's failure to ensure a system is in place to provide appropriate and safe sterilization in accordance with standards of practice, Ophthalmic (eye) Surgical Instruments Handling Instructions, and in accordance with the Steris sterilizers operating instructions puts all individuals who have cataract surgery at risk for harm, injury, infection or even death.

Findings Include:

According to the Katena (provider of ophthalmic surgical instruments) Surgical Instruments Handling Instructions that the hospital uses for cataract surgeries, Immediate-Use (Flash) is sterilization cycling that is designed to manage unanticipated, urgent needs for instruments. Immediate use sterilization should not be used to save time or as a substitute for instrument inventory.

Observation on 09/12/18 at 7:50 AM, Staff JJ demonstrated the cleaning and packing of the eye instruments that had just been used for a cataract surgery. He placed the eye instruments in the "One Tray" (a sealed sterilizartion container) and carried the tray to the Steris Amsco Century V120 sterilizer located in the hallway. He pressed Cycle 1 on the touch pad and said that they always use Cycle 1 to sterilize the eye instruments trays between cataract surgery cases. Touch Pad Cycle 1 showed settings of: Pre-Vacuum, 270 degrees, Sterilize 4 minutes and Dry time 1 minute.

During an interview on 09/12/18 at 9:12 AM, Steris Representative 1 stated that the Flash, Immediate Use Steam Sterilization cycle has a dry time of 1 minute.

Review of Steris Amsco Century V120 sterilizer print out for 09/12/18 showed the hospital staff sterilized the cataract eye surgery instruments using IUSS.

Staff OO, Physician, used these instruments during cataract surgeries for 8 of 12 scheduled cases (Patient 31-38). The hospital canceled surgery for the remaining four patients scheduled for cataract surgery on 09/12/18.

Review of the Steris Amsco Century V120 sterilizer print out for 08/08/18 showed the hospital staff sterilized the cataract eye surgery instruments using IUSS.

Staff OO, Physician, used these instruments during cataract surgeries for 13 patients (Patient 43-45, 47-56) on 08/08/18. Staff PP, Physician, used these instruments during cataract surgeries for 1 patient (Patient 46) on 08/08/18.

Review of the Steris Amsco Century V120 sterilizer print out for 08/29/18 showed the hospital staff sterilized the cataract eye surgery instruments using IUSS.

Staff OO, Physician, used these instruments during cataract surgeries for 12 patients (Patient 32, 33, 35, 36, 38-40, 53 and Patient 57-60) on 08/29/18.

During an interview on 09/12/18 at 9:49 AM, Staff GG, Registered Nurse (RN), Operating Room (OR) Director, stated that they routinely use the Steam Cycle: Immediate Use (Flash) as listed on the Katena Surgical Instruments Handling Instructions to sterilize the cataract surgery instruments between patients.


(Refer to Tag A 0749 for further details).

Based on observation, staff interview, document review, and policy review the Infection Control Officer (ICO) failed to ensure proper sterilization of cataract surgery instruments increasing the risk of transmitting infections and communicable diseases by routinely using Immediate Use Steam Sterilization (IUSS) of instruments used during cataract surgery for 26 of 30 patients (Patient's 30-38 and 43-60) scheduled for surgery on 08/08/18, 08/29/18 and 09/12/18; failed to ensure a system of identifying and controlling infections in the newborn nursery for one of one refrigerators; failed to ensure staff followed the surgical attire standards and policy by wearing masks dangling around the neck (Staff KK, HH, LL, and 3 unidentified staff), failed to ensure all staff wore surgical caps and beard covers to prevent exposed hair (Staff KK), failed to clean the hub of the Intravenous line prior to injecting medication (Staff KK and MM for Patient 21) and failed to ensure staff followed the hand hygiene policy (Staff HH).

Failure to ensure instruments in cataract surgery cases had been sterilized according to infection control standards and manufacturer's operating instructions for the sterilizer and cataract surgical instruments has the potential to cause serious injury, harm, impairment or death to a patient.

Failure to ensure breast milk and meconium are stored in different location, ensure staff followed surgical attire standard, hand hygiene, and safe injection practices places all patients at an increased risk of contracting an infection.

Findings Include:

Review of the Cataract surgery schedule on 09/10/18 showed there were 12 patients scheduled for cataract surgery on 09/12/18 starting at 7:00 AM and the last one scheduled at 12:30 PM.

During an interview on 09/10/18 at 3:15 PM Staff GG, Registered Nurse (RN), Operating Room (OR) Director stated that they have two physicians that perform cataract surgeries. Each physician usually comes twice a month. She said that they have four cataract surgery instrument trays. Since Staff OO, Physician, brings in his own Phaco tips and handpieces (instruments used during cataract surgery that vibrates rapidly back and forth reducing the diseased lens to a liquid by ultrasonic vibrations), we sterilize these instruments using IUSS prior to the first four cases of a day. She stated that they sterilize the cataract instrument trays using "One Tray" (a rigid container used to place instruments in for sterilization) and IUSS on all the cataract surgery instruments between surgical cases.

Document review of the American Academy of Ophthalmology's (AAO's) Guidelines for the Cleaning and Sterilization of Intraocular (eye) Surgical Instruments - 2018 showed: Complete terminal, wrapped sterilization cycles should be used to sterilize ophthalmic surgical instruments that will be stored overnight for future use. Short-cycle steam sterilization is commonly used for what we refer to as sequential same-day ophthalmic procedures; that is, subsequent consecutive surgeries occurring on the same day the instruments are sterilized.

AAO further indicated that IUSS (Flash) might be used on an emergent basis to provide instruments to the Operating Room (OR) for a surgical case that is already underway. "IUSS is not the same thing as "short-cycle" sterilization, which is a form of terminal sterilization that is acceptable for routine use for a wrapped/contained load where pre-cleaning of instruments is performed according to the manufacturers' instructions, and the load meets the device manufacturer's instructions for use (IFU), includes use of a complete dry time and is packaged in a wrap or rigid sterilization container validated for later use. Use of short-cycle sterilization is particularly common in facilities that perform eye surgery and is acceptable when all IFU (i.e., sterilizer, device, and container manufacturer's) are followed...Facilities performing surgery should understand the differences between IUSS and short cycle sterilization in order to ensure that they comply with infection prevention and control requirements".

Document titled "Katena (provider of ophthalmic (eye) surgical instruments) Surgical Instruments Handling Instructions" provide by Staff GG, showed, Sterilization - We recommend that you sterilize your Katena surgical instruments using steam autoclave procedures that are regularly used in hospitals and surgery centers. The following table provides the suggested cycles based on Association for the Advancement of Medical Instrumentation (AAMI) and Association of periOperative Registered Nurses (AORN) recommended standards.

1. Steam Cycle: Pre-Vacuum; Preparation: Wrapped; Temperature: 270 degrees; Exposure Time 4 minutes; Drying Time: 20 minutes

2. Steam Cycle: Pre-Vacuum; Preparation: Wrapped; Temperature: 273 degrees; Exposure Time: 3 minutes; Drying Time: 20 minutes

3. Immediate-Use (Flash)*; Preparation: Unwrapped; Temperature: 270 degrees; Exposure Time: 3 minutes; Drying Time: N/A
*Immediate-Use (Flash) is sterilization cycling is designed to manage unanticipated, urgent needs for instruments. Immediate use sterilization should not be used to save time or as a substitute for instrument inventory.

Review of the "ONE TRAY" product manual users guide showed: The performance and intended use of the ONE TRAY Sealed Sterilization Containers should utilize the:
- Device Manufacturers' sterilization exposure parameters
- Recommended practices/guidelines outlined by AAMI (Association for Advancement if Medical Instruments), AORN (Association of periOperative Registered Nurses).
- Medical Devices should be prepared and sterilized according to the device manufacturer sterilization exposure parameters.

Review of the document titled, ONE TRAY 510 (k) Summary of Safety and Effectiveness," dated March 13, 2006, showed the performance and intended use of ONE TRAY Sealed Sterilization Containers should comply at all times with the methods of use and flash sterilization guidelines as recommended by the manufacturer of the devices being sterilized ...

The hospital failed to provide any documentation from the instrument manufacturer (Katena) verifying the use of ONE TRAY with the IUSS (flash) cycle complied with their sterilization exposure parameters.

Review of the hospital policy titled, "Immediate Use Steam Sterilization," showed, This policy outlines the procedure for the adequate sterilization of surgical instruments and equipment using immediate use steam sterilization in the instance of emergency situations and/or when there is insufficient time to sterilize an item by the preferred prepackaged methods and/or manufacturers recommendation.

Observation on 09/12/18 at 7:50 AM, Staff JJ demonstrated the cleaning and packing of the eye instruments that had just been used for a cataract surgery earlier this morning. He placed the eye instruments in the "ONE TRAY" and sealed the tray. He carried the tray to the Steris Amsco Century V120 sterilizer, placed the ONE TRAY in the sterilizer, closed the door and pressed Cycle 1 on the touch pad and said that they always use to sterilize the eye instruments. Touch Pad Cycle 1 showed settings of: Pre-Vacuum, 270 degrees, Sterilize 4 minutes and Dry time 1 minute. Staff JJ stated that he thought the cycle was 4-minute sterilization with a 20-minute dry time. He stated that Cycle 1 was what they used for all of the eye instrument trays between cataract surgery cases.

During an interview on 09/12/18 at 9:12 AM, Steris Representative 1 stated that the Flash, Immediate Use Steam Sterilization has a dry time of 1 minute. He stated that the sterilizer cycle setting on page 4-8 of the operation manual for the sterilizer shows the preset PreVac Cycle would have a minimum dry time of 16 minutes for instrument trays with a maximum of 17 pounds.

Review of the Operating Instructions for the Steris Amsco Century Gravity and PreVacuum (PreVac) Sterilizer showed the following: Table 4-1 Factory-Set Cycles and Cycle Values:
1. Cycles: Flash; Sterilizer Temp. 270 degrees Fahrenheit (F); Sterilize Time 3.0 minutes; Dry Time 1.0 minutes; Recommended Load Unwrapped instrument tray with a single instrument; Validation Standard ST-37. This cycle is for sterilizing an unwrapped item intended for immediate use (e.g., a dropped instrument);
2. Cycles: Flash; Sterilizer Temp. 270 degrees Fahrenheit (F); Sterilize Time 10.0 minutes; Dry Time 1.0 minutes; Recommended Load Unwrapped instrument tray with non-porous multiple instruments, maximum weight 17 pounds (lbs.);
3. Cycles: Express (Instrument trays processed using this cycle are intended for immediate use); Sterilizer Temp. 270 degrees Fahrenheit (F); Sterilize Time 4.0 minutes; Dry Time 3.0 minutes; Recommended Load Single wrapped instrument tray with a single instrument, non-porous goods, only;
4. Cycles: PreVac, Sterilizer Temp. 270 degrees Fahrenheit (F); Sterilize Time 4.0 minutes; Dry Time 20.0 minutes; Recommended Load Up to two double wrapped instrument trays, maximum weight 17 lbs. each. Up to six fabric packs;
5. Cycles: PreVac, Sterilizer Temp. 275 degrees Fahrenheit (F); Sterilize Time 3.0 minutes; Dry Time 16.0 minutes; Recommended Load Up to two double wrapped instrument trays, maximum weight 17 lbs. each.

During an interview on 09/12/18 at 9:49 AM, Staff GG stated that they routinely use the Steam Cycle: Immediate Use (Flash) as listed on the Katena Surgical Instruments Handling Instructions to sterilize the cataract surgery instruments between patients.

Review on 09/12/18 of Steris Amsco Century V120 sterilizer print out for 09/12/18 showed the cataract eye surgery instruments were sterilized using IUSS with cycle settings as follows:
- Sterile Temperature (Temp) = 270 degrees Fahrenheit (F);
- Control Tem = 273 degrees F;
- Sterile Time = 4 minutes; and
- Dry Time = 1 minute;
The instruments were used for 8 of 12 patients scheduled for cataract surgery (Patients 31 - 38) on 09/12/18. Surgery was canceled for the remaining four patients scheduled for cataract surgery that same day.

Review of Steris Amsco Century V120 sterilizer print out for 08/08/18 showed the cataract eye surgery instruments were sterilized using IUSS with cycle settings as follow:
- Sterile Temperature (Temp) = 270 degrees Fahrenheit (F);
- Control Temp = 273 degrees F;
- Sterile Time = 4 minutes; and
- Dry Time = 1 minute;
The instruments were used during surgery for 14 patients (Patients 43 - 56).

Review of Steris Amsco Century V120 sterilizer print out for 08/29/18 showed the cataract eye surgery instruments were sterilized using IUSS with cycle settings as follows:
- Sterile Temperature (Temp) = 270 degrees Fahrenheit (F);
- Control Temp = 273 degrees F;
- Sterile Time = 4 minutes; and
- Dry Time = 1 minute;
The instruments were used during surgery for 12 patients (Patient 32, Patient 33, Patient 35, Patient 36, Patient 38 - 40, Patient 53, and Patients 57- 60).


Document review of the hospital's undated document titled, "Medtox Chain of Custody Meconium Collection Instructions," showed continue collecting and pooling the meconium (meconium is the early feces (stool) passed by a newborn soon after birth, before the baby starts to feed and digest milk or formula) into the same collection vial until 2-5 grams are collected or until the first milk stool appears. Between collections, cap and store the specimen in a secure refrigerator. Multiple collectors may be involved...meconium specimens should be refrigerated in a secure area between collections until they are ready to be shipped.

Document review of the hospital's policy titled, "Breast Milk Collection and Storage," reviewed 07/17, showed each patient's breast milk should be stored in a separate bin to discourage misadministration and cross contamination...breast milk will be stored in a designated refrigerator and freezer unit in the nursery.

Observation on 09/11/18 at 9:39 AM, in the newborn nursery, showed a small refrigerator with an unlabeled container of meconium (a newborn's first stool), and a syringe of breast milk with the date of 09/03/18 on the same shelf.

During an interview on 09/11/18 at 9:39 AM, Staff H, I, and J, Registered Nurses (RN), verified the unlabeled container of meconium and syringe of breast milk dated 09/03/18 were located in the same refrigerator on the same shelf in the newborn nursery.

During an interview on 09/11/18 at 11:03 AM, Staff G, Obstetrics Director, Registered Nurse (RN) stated that the meconium and breastmilk should not be stored in the same refrigerator for infection control issues.


Association of periOperative Registered Nurses (AORN) 2012 Guidelines at VI.b.1 read, Masks should not be worn hanging down from the neck. The filter portion of a surgical mask harbors bacteria collected from the nasopharyngeal airway. The contaminated mask may cross-contaminate the surgical attire top."

Observation on 09/11/18 at 11:10 AM, Staff HH, RN Circulator arrived in the preoperative area with a mask dangling around her neck to get Patient 21 for surgery. She wore the mask dangling around her neck until she arrived at OR 4, she then put the mask up over her mouth and nose and tied it at the back of her head before entering OR 4 with Patient 21.

Observation on 09/11/18 at 1:20 PM showed an unidentified staff walking in the hall towards the clinics with a surgical mask dangling around his neck.

Observation on 09/11/18 at 1:25 showed three unidentified staff sitting in the operating room nurse's station with surgical masks dangling around their necks.

Observation on 09/11/18 at 2:00 PM showed Staff LL, Scrub Tech in the Surgical Central Supply room with a surgical mask dangling around her neck.

During an interview on 09/11/18 at 2:00 PM in the Surgical Central Supply room, Staff LL stated that she should have taken her mask off. She said that she had gone into the OR to open for her case and then didn't take it off. She said that we are supposed to take the masks off. She removed the mask and threw it in the trash.

During an observation on 09/11/18 at 3:00 PM showed Staff HH came out of OR 4, she removed her mask outside of OR 4, reached into the box of masks without performing hand hygiene, tied the new mask around her neck and walked to the preoperative area with the mask dangling around her neck. She returned to the surgical suite area with a patient and her mask was still dangling around her neck, she put the mask up over her nose and mouth before entering OR 3.

During an interview on 09/11/18 at 2:34 PM Staff GG, OR Director stated that they do not have a policy specifically for masks. She stated that the masks should be changed in between cases and if staff leave the department they are to change their mask.


Review of hospital policy titled, "Operating Room Infection Control" showed, Asepsis of the operating room, instruments and equipment along with surgical attire and performance of personnel is extremely important..., ...B. Attire: 4. Hair must be covered by a surgical cap. 5. Facial hair must be covered with beard covers.

Review of hospital policy titled, "Infection Control: Guidelines for Anesthesia", showed: To prevent infection and spread of communicable disease. All other appropriate hospital infection control policies and procedures will be followed, ...1. Personnel, b. Wear surgical caps that completely cover the hair.

Observation on 09/11/18 at 11:15 in OR 4 showed Staff KK, Medical Doctor (MD), Director of Anesthesia, had hair on the back of his head and sideburns exposed and not covered by a surgical cap or beard cover while in the operating room caring for Patient 21.

Observation on 09/11/18 at 2:35 PM showed Staff KK walking through the Surgical Suite hall with his mask dangling, hair exposed from under the surgical cap and sideburns not covered.

During an interview on 09/12/18 at 2:15 PM, Staff KK stated that he doesn't cover his eyelashes or eyebrows and thinks its "silly" to wear the surgical cap over the skull cap to cover his hair.


Review of hospital policy titled, "Operating Room Infection Control" lacked evidence of direction to staff addressing non-cleanable papers taped to the wall in the operating rooms.

Observation of the terminal clean of OR 4 on 09/11/18 at 3:20 PM showed non-cleanable papers taped to the wall by the charting area and supply closet.

During an interview on 09/11/18 at 3:45 PM, Staff GG stated that there is no policy addressing noncleanable surfaces in the OR. She said that it is common sense. She stated that someone must have updated the forms and did not laminate them.


Association for Professionals in Infection Control, APIC POSITION PAPER: SAFE INJECTION, INFUSION, AND MEDICATION VIAL PRACTICES IN HEALTH CARE (2016). Disinfect catheter hubs, needleless connectors, and injection ports before accessing. Use either an antiseptic containing port protector cap or vigorously apply mechanical friction with chlorhexidine/alcohol, sterile 70% isopropyl alcohol, or other approved disinfectant swab.

Review of hospital policy titled, "Intravenous Therapy and Line Care" showed, Administration of Intermittent Medications b. prep top of injection cap with alcohol...

Observation on 09/11/18 at 11:15 AM in OR 4, showed Staff KK injecting medication into Patient 21 intravenous (IV) line without cleaning the hub with alcohol prior to connecting the syringe to the IV port.

Observation on 09/11/18 at 11:18 AM in OR 4, Staff KK, attach the IV antibiotic tubing to the intravenous line without cleaning the connection hub with alcohol.

Observation on 09/11/18 at 11:45 AM in OR 4, showed Staff MM, Certified Registered Nurse Anesthetist (CRNA), failed to clean the hub of the IV line prior to injecting medication.

During an interview on 09/12/18 at 2:15 PM, Staff KK stated that he has not seen an official policy on cleaning the hub before injecting medications. He said that he hasn't seen cleaning the hub in other facilities.


Review of hospital policy titled, "Hand Hygiene" showed, Wash hands after removing gloves.

Observation on 09/11/18 at 11:49 AM showed Staff HH, RN removed her gloves and did not perform hand hygiene.

Observation on 09/11/18 at 3:00 PM showed Staff HH left OR 4, she removed her mask, and then reached into a box of clean masks without performing hand hygiene.