HospitalInspections.org

Based on observation, review of policies and procedures, staff interview, and review of sterilization and disinfection logs the facility failed to implement a system for ensuring mobile vacuum devices and laryngoscope handles were disinfected prior to use. The findings were:

1. Observation of the operating room and surgical area on 8/24/16 at 8:20 AM revealed an uncovered waste management system (a high powered mobile vacuum device used for disposing surgical fluid waste in the operating room during surgery) was positioned near the wall in the instrument cleaning room. Interview with central sterile technician at that time revealed the following information: The instrument cleaning room was a "dirty" room because it was a room used to clean dirty instruments. The waste management systems were disinfected after use and stored in the dirty room until needed in the operating room. When needed, the waste management systems were moved from the dirty room into the operating room and used, without disinfection. During an interview on 8/24/16 at 1:30 PM the operating room manager verified the waste management systems were not stored in a manner to prevent cross contamination, nor were they disinfected prior to use. He further stated he had not thought about it until talking with the surveyor and realized they needed to ensure the waste management systems that entered the operating room were free from recontamination. Interview with the infection control preventionist on 8/24/16 at 1:30 PM revealed they systems were at risk of recontamination while stored in the dirty room and use without disinfection was not an acceptable standard of practice for infection prevention.

2. Observation on 8/24/16 from 7:40 AM to 8 AM revealed unpackaged and unlabeled Laryngoscope handles were stored on top of anesthesia carts and in drawers in operating rooms 1 and 2. Further observation revealed the handles were stored in the same manner in the cart in the recovery area. Interview with the operating room manager during the observation revealed staff routinely disinfected the handles after use, but the manner in which they were stored made it difficult to determine whether recontamination had occurred. He further stated the staff had to assume the handles they used had been disinfected because the facility did not have a system for identifying or labeling which handles had been disinfected. Review of the sterilization and disinfection logs for 2/1/16 to 8/23/16 showed no record of cleaning and disinfecting laryngoscope handles.

3. Review of the 2015 Edition of Guidelines for Preoperative Practice, published by AORN (Association of Peri-Operative Registered Nurses), revealed the following recommendation: "XII.c. Cleaned and disinfected laryngoscope blades and handles should be packaged and stored in a manner that prevents contamination..."

4. Review of the policy and procedure titled, "Sterilization" dated 6/2016, revealed, "...The creation and maintenance of an aseptic environment can directly influence patient outcomes. One of the measures for preventing surgical site infections (SSIs) is to provide reusable surgical items that are free of contamination at the time of use. This can be accomplished by subjecting them to cleaning and decontamination, followed by high-level disinfection (HLD) or sterilization. The expected outcome is that the patient will be free from signs and symptoms of infection."