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SAINT ROSE DOMINICAN HOSPITALS - SAN MARTIN CAMPUS
INFECTION CONTROL PROGRAM
Tag No.: A0749
Based on observation, interview, and record review, the facility did not ensure that measures to prevent infection were employed.
Findings include:
On 11/22/2011 at 12:57, Employee #5, a Medical Doctor, was observed to listen to a patients breath sounds using a stethoscope. The employee was wearing gloves. She then took off the gloves, threw them away, and exited the room without cleaning her hands or using an alcohol based hand rub.
On 11/22/2011 at 2:34 PM, Employee # 19, a Respiratory Therapist, was observed prepare a nebulizer treatment. She dropped a unit dose of Albuterol on the floor and was observed to pick it up and begin again to administer the dose. The surveyor stopped the therapist and she washed her hands and retrieved a new unit dose.
On 11/22/11 at 1:00 AM, Employee #11 was observed cleaning surgical instruments with Prolystica Concentrate Enzymatic Presoak and Cleaner in the decontamination area. Employee #11 did not know the manufacturers recommended concentration levels of Prolystica Enzymatic cleaner to water. Employee #11 did not know the manufacturers recommendations for soak time of 2 to 5 minutes for surgical instruments and was observed washing surgical instruments in the decontamination sink for 15 to 20 seconds prior to rinsing and removing the instruments from the sink.
On 11/22/11 at 10:00 AM during a tour of the pre-operative and post anesthesia recovery units numerous oral suction catheters located in designated clean bays that were attached to suction canisters were observed inside packages where the seal had been opened. Nursing staff indicated all the oral suction catheters were opened for potential quick use by nurses who may need to suction a patient. Nursing staff questioned did not know if the oral catheters had been used on previous patients or if they were contaminated or clean.
On 11/22/11 at 10:00 AM during a tour of the pre-operative and post anesthesia recovery unit nursing staff did not know where the facility blood spill kits were located and could not produce a blood spill kit during the tour of the pre-operative and post anesthesia recovery room areas.