HospitalInspections.org

Based on observation, interview and record review, the hospital failed to ensure that sanitary practices were implemented to avoid the transmission of infections and communicable diseases, in 2 of 4 areas observed (Obstetrics and Sterile Processing).

Findings include:

1) The hospital failed to ensure that brushes used for surgical instrument cleaning were disposable or given daily disinfection or sterilization. (A0749)

2) The hospital failed to ensure that obstetric birthing rooms were sanitized immediately after delivery to prevent the potential spread of blood borne pathogens. (A0749)

The cumulative effects of these surgical and environmental infection control failures resulted the hospital's inability to promote the health and safety of their patients.

Based on observation, interview and record review, the hospital failed to ensure that potentially infectious biohazardous waste was removed from patient care equipment using appropriate cleaning and disinfection methods, in 2 of 4 areas observed (Obstetrics and Sterile Processing).

Findings include:

1) The hospital failed to have Observation of the sterile processing decontamination area on 11/30/2017 at 11:40 a.m. revealed a container of 3 used (bristles splayed) brushes (toothbrush-type with no brand name) sitting on the decontamination sink used to clean biohazardous waste from surgical instruments before sterilization.

During interview with Peri-operative Supervisor A on 11/30/17 at 11:40 a.m., A stated that these "brushes are reused", and that daily disinfection/sterilization of the brushes "is not done".

2) Observations in Birthing Room (BR) 6 on 11/30/17 at 12:30 p.m. revealed that Patient #10 delivered a child, while accompanied by husband and sister, and had a large amount (approximately 300-500 milliliters) of post delivery vaginal bleeding. Visible post-delivery blood splatter was observed at the foot (dime-sized spray droplets) and to the left side of the delivery bed (2 pools approximately 2-3 inches in diameter).

Observations of environmental cleaning of BR 6 on 11/30/17 at 3 p.m., after Patient #10 was moved into a post-partum room, revealed that blood splatter and spray had not been removed from floor. Patient #10's visitors and hospital staff had the potential to walk in bloody biohazardous materials tracking them outside of this room. During observation of the room cleaning by EVS (Environmental Services Staff) B, B did not clean up the blood spills immediately before cleaning all other areas of the room. When the bottom portion of the birthing bed was taken apart, a large pool of blood was observed in the large birthing dump bucket (designed to contain birthing blood and fluids). B took this bucket into the bathroom and rinsed it of blood, was observed to wipe the inner and outer surface with a saturated disinfectant cloth. B, then attached the bucket onto the bed. After rinsing this bucket, B failed to clean, then disinfect it's surfaces.

The 12/4/17 record review of the "Sealed Air, Diversity Care-Blood and Body Fluids Cleaning Procedures" provided by EVS Director C on 12/4/17 at 3:30 p.m. revealed "In labs, research areas, and other high risk areas, with a large spill, use these steps... 3. Clean the surface using an appropriate cleaner or cleaner disinfectant to remove all of the gross soil and any BBF (blood and body fluid) residues. 4. Disinfect the surface with registered disinfectant that containers a blood-borne pathogen claim and apply according to the directions on the label."

The 12/4/17 record review of the "CDC (Centers for Disease Control) Guidelines for Environmental Infection Control in Health-care facilities, June 6, 2003 (RR5210)" reveals under "II. Cleaning of Spills of Blood and Body Substances, A. Promptly clean and decontaminate spills of blood or other potentially infectious materials."