HospitalInspections.org

Based on policy review, manufacturer's guidelines, observation and interview, the facility failed to adhere to manufacturer's guidelines and policies for cleaning and disinfecting of the surgical equipment and surgical environment.

The findings included:

1. Review of the facility's "Surgery/Delivery Terminal Cleaning" policy documented, "...Manual Dilution Method - Wet mop method - fill mop bucket with two (2) gallons of water. Pump 1/2 oz. [ounce] disinfectant per gallon of water. Mop water should be changed after each room..."

2. Review of the manufacturer's guidelines "ENDOZIME" documented, "...Add one (1) ounce (1 pump) of ENDOZIME to one (1) gallon (8 ml/liter) of water. Submerge instruments and scopes to be cleaned...Soak for 2 minutes to remove all organic soils..."

3. Review of the facility's "Enzymatic Detergent" policy documented, "...Enzymatic detergent is an enzyme-based, presoak-plus-cleaner designed to thoroughly clean instruments before they are disinfected or sterilized. Enzymatic detergent's proteolytic enzyme enhances the cleaning process by penetrating and lifting off tough, dried-on, hard-to-reach organic matter from endoscopic instruments and general equipment...Apply to instruments immediately after use and follow manufacturer's guidelines..."

4. Review of the manufacturer's guidelines "Virex 256" documented, "...When used as directed at a 1:256 dilution (1/2 oz. (1 pump) per gallon of water), this product contains 660 ppm of active quaternary germicide making it highly effective against a wide variety of pathogenic microorganisms..."

5. Observation in the Scope cleaning room on 8/28/12 at 9:35 AM, revealed the sink in the room used to clean and soak the scopes had no markings or identifiers to show the water fill line in order to determine the correct amount of water.

During an interview in the Scope cleaning room on 8/28/12 at 9:35 AM, the Surgical Technician (Tech) #1 was asked how is the ENDOZIME mixed to clean the scopes. Surgical Tech #1 stated, "...I use 4 pumps which is 4 ounces to 4 gallons of water...No, there is no fill line in the sink I just eye where it [water] goes..."

6. Observation in the surgery department hallway outside OR #1 on 8/28/12 at 10:00 AM, revealed on the Environmental Services (ES) cart a large bucket containing clear liquid with mop heads floating.

During an interview in the surgery department hallway outside OR #1 on 8/28/12 at 10:00 AM, the ES #1 employee was asked what was in the bucket and how was it mixed. The ES #1 employee stated, "...It is Virex 256...I use 2 pumps and add water...No, there is no water fill line on the bucket...No I don't measure it, I just fill it to where I think..."

During an interview in the surgery department hallway outside OR #1 on 8/28/12 at 10:00 AM, the Linen/ES Supervisor confirmed there was no water fill line on the bucket and no measurement system for the employee to use to accurately measure the amount of water to be mixed with the disinfectant. The Linen/ES Supervisor stated, "...If it doesn't get the proper ratio then doesn't kill germs like it should..."