HospitalInspections.org

Based on document review, medical record review and interview, the facility failed to ensure policies and procedures were developed and/ implemented to avoid the transmission of infections and communicable diseases. Lack of policies and lapses in infection control practices led to a contaminated endoscope being utilized on Patient #1.


See Citation: Tag A749.

Based on document review, medical record review and interview, the facility failed to ensure policies and procedures were developed and/ implemented to avoid the transmission of infections and communicable diseases. Specifically, staff did not "turn over" the procedure room and/or remove the endoscope following an endoscopic procedure. Outgoing staff did not conduct "hand-off" reporting related to the readiness of the procedure room to the oncoming staff. Lack of policies and lapses in infection control practices led to a contaminated endoscope being utilized on Patient #1.

Findings include:

Review of the facility's event reporting system dated 09/21/16 revealed that an "EGD" (esophagogastroduodenoscopy) scope used on Patient #1 that was not properly cleaned. Patient #1 was notified and the appropriate follow-up testing completed with Patient #1 and the source patient.

Review of medical record for Patient #1 revealed on 09/21/16 at 02:40 PM she underwent an EGD with biopsy. On 09/22/16 at 02:47 PM the physician note indicates that yesterday (09/21/16), it was disclosed to Patient #1 and her husband that a contaminated endoscope was used for her procedure inadvertently. The physician discussed that appropriate laboratory studies will be ordered for her and the source patient (Patient #2). Questions were answered and she verbalized understanding. Follow up will take place after results are received.

Interview on 09/30/16 at 09:15 AM with Staff #2 and Staff #4 revealed that the first shift registered nurses (RN), Staff #12 and Staff #13, had finished the case for Patient # 2 (source patient). Staff #10 and Staff #11, the second shift RN ' s were taking over and starting the next case for Patient #1, saw the endoscope on tray set up and thought the room was ready. During Patient #1 ' s procedure, Staff #17, MD noted that the trap was on the endoscope and questioned why it was there. Staff #10 and Staff #11 realized after the case that the endoscope from the previous patient (Patient #2) had not been decontaminated and was used on Patient #1.

Interview on 09/30/16 at 10:05 AM with Staff #7, Surgical Technician revealed that she went into procedure room to see if Staff #10 and Staff #11, second shift RN ' s needed help. The scope was upside down and she questioned the nurses about this. The endoscope tag was next to the endoscope. Staff #7 told the nurses that this is not how she sets up her tables. She stated that she did not set up the table for this case. Staff #7 did not report her concerns related to the endoscope table setup to anyone but Staff #10 and Staff #11.

Interview on 09/30/16 at 11:00 AM with Staff #10 and Staff # 11 revealed that the nurses from the early shift came out of Endoscopy room with the previous patient (Patient #2) at 02:14 PM and were scheduled to end their shift at 02:30 PM. Staff #10 and 11 stated that they checked to be sure the endoscope tag was on table. They thought the room had been set up by the previous nurses. Staff #10 stated that physician noticed the trap on endoscope during the procedure and she should have realized there was a problem with the endoscope. Staff #10 indicated that Staff #7, Surgical Technician told her that was not the way she placed an endoscope on the table, but did not tell her that she had not set up a new scope. Staff #10 stated she thought scope had been moved by previous staff. Staff #10 and 11 stated when they realized the endoscope set up was from the previous patient (Patient #2), they reported the incident to Staff #9, the Nurse Manager.

Interview on 09/30/16 at 12:20 PM with Staff #12 and Staff #13 revealed that they were the first shift RN ' s assisting with the Endoscopy procedure for Patient #2 (source patient). Staff # 13 stated that they immediately left the room at end of procedure to take Patient #2 to the recovery room. Staff #13 stated that the endoscope was still in the room and that they were unaware that Staff #15 (Endoscopy aide) was out of the department. Staff #13 stated that she told Staff #10, second shift RN that she had changed the towel and labeled the time on new water cup for specimen table for the next patient (Patient #1). Staff #13 stated that she did not report that the room was ready for the next patient and no shift change report was given.

Review of policy "Medivator-Reprocessing in Endoscopy" last revised 04/17/15 indicates to transport the endoscope in designated waterproof cinch type bag to endoscope reprocessing area following the procedure. No evidence was found to indicate the facility has a policy to specifically addressed GI/Endoscopy room set-up, room turn over and/or a protocol to properly identify the endoscope (tag) prior to the procedure.

Review of policy "Hand Off Communications with Physicians/Caregivers" last revised 01/15 revealed "hand off" communication will occur at shift change on nursing units, can be verbal and/or written and should address pertinent up-to-date information regarding the patient ' s treatment, care and services, as well as current condition and any recent or anticipated changes.

Review of policy "Speak Up for Safety" effective 08/16 revealed to directly communicate the identified problem to the available members of the team, including but not limited to, the attending physician, nurse and/or other clinicians. Stop the process and get management involved.