HospitalInspections.org

Based on observation, policy review, label review, and interview, the provider failed to:
*Clean a blood draw chair between patients.
*Verify the strength of a high level disinfectant used to disinfect semi-critical medical devices before each use.
*Maintain the clean storage room in the operating suite.
*Ensure one of one whirlpool bath was properly disinfected between uses.
Findings include:

1. Observation, policy review, and interview on 7/25/11 at 4:27 p.m. in the laboratory (lab) with medical technologists A and B revealed:
*There were two blood draw chairs. The chairs were cleaned twice a day at 1200 (noon) and 1700 (5:00 p.m.) hours and when visibly soiled.
*Multiple patients used the chair between each cleaning and had direct skin contact with the arms of the chair.
*They were following the hospital policy for cleaning the chair.
*Review of the policy and procedures for the lab dated 5/18/11 confirmed the above cleaning policy.

2. Observation, label review, and interview on 7/26/11 at 9:10 a.m. in the decontamination room with the purchasing director revealed:
*She cleaned and disinfected the gastrointestinal (GI) scopes after each scope was used.
*She was using Cidex OPA as the disinfectant for the GI scopes.
*She tested the disinfectant once each day before GI scopes were cleaned and disinfected.
*Some days she would process multiple GI scopes using the Cidex OPA.
*Review of the label for the Cidex OPA test strips revealed the Cidex OPA was to be tested before each use.
*She was not aware the Cidex OPA should have been tested before each use.

3. Observation and interview on 7/26/11 at 9:40 a.m. in the clean/sterile supply room in the operating suite with the purchasing director revealed:
*There were cardboard shipping boxes stored on the shelves (photos 1, 2, and 3).
*She was not aware the shipping boxes were being used in the clean/sterile supply room.
*She agreed the shipping boxes were not clean and should not have been used in the clean/sterile supply room.

4. Interview on 7/27/11 at 9:13 a.m. with the director of nursing revealed:
*She agreed the blood draw chairs should have been cleaned between each patient.
*She agreed the Cidex OPA should have been tested before each use.
*She agreed cardboard shipping containers were not clean and should not have been stored in the clean/sterile supply room of the operating suite.

5. Interview and label review on 7/27/11 at 10:00 a.m. with patient care technician C revealed:
*She was responsible for bathing patients and disinfecting the whirlpool tub.
*She would fill the tub completely full and add about three ounces of whirlpool disinfectant to the tub when disinfecting it between uses.
*Review of the label for the whirlpool disinfectant revealed two ounces per gallon of water was to be used to disinfect.
*She agreed three ounces would not be enough disinfectant to disinfect a full whirlpool tub.

6. Interview on 7/27/11 at 10:30 a.m. with the director of patient care services revealed:
*She agreed the blood draw chairs should have been cleaned between each patient. The quality assurance committee had recently discussed that and had decided to change the policy. She was not sure why the policy had not been updated.
*She agreed the Cidex OPA should have been tested before each use.
*She agreed cardboard shipping containers were not clean and should not have been stored in the clean/sterile supply room of the operating suite.
*She agreed three ounces of disinfectant would not have been enough to disinfect a full whirlpool tub.