HospitalInspections.org

32355




32572




20031

Based on observation, interview, and document review, the provider failed to ensure:
*Three of three endoscopes (lighted tubes to view inside specific areas of the body) were stored protected from possible contamination in the supply room of the surgical suite.
*Three of three gurneys (a flat, padded table with wheels used to transport patients) in two of two rooms (emergency room [ER] and the operating room [OR]) were maintained in a cleanable condition.
*A stack of paper towels used for two of two scrub sinks were stored and dispensed to prevent possible contamination.
*One of one water spigot with an attached hose in the scope processing area had a vacuum breaker to prevent possible backflow into the clean water.
Findings include:

1. Observation on 6/10/15 at 1:00 p.m. revealed three endoscopes were hung on the wall in the supply closet next to the scrub area of the surgical suite. Those scopes were not in an enclosed ventilated cabinet to protect them from possible contamination. Interview with surgical technician (ST) A at the time of the observation confirmed that finding. She stated she had some concerns about how the scopes were stored. However, that was how those scopes had always been stored.

Review of the AORN 2014 guidelines for Cleaning and Processing Endoscopes, p. 534, revealed:
*"Flexible endoscopes should be stored in a manner that protect the device form damage and minimizes microbial contamination.
IX.a. Flexible endoscopes should be stored in a closed cabinet with:
-venting that allows air circulation around the flexible endoscopes;
-internal surfaces composed of cleanable material;
-sufficient space for storage of multiple endoscopes with touching."
*Glossary p. 539, revealed:
"High-level disinfection: "Government-registered high-level disinfection agents kill vegetative bacteria,..."

Surveyor: 32572
2. Observation on 6/9/15 at 9:45 a.m. of the OR revealed the one gurney had cracks in the vinyl on the corners of the three foam pads. Those cracks exposed the webbing and foam beneath the vinyl. Interview with the director of patient services at the time of the observation confirmed those pads were uncleanable and could create a source of contamination for the surgical patients.

Surveyor: 29354
3. Observation on 6/9/15 at 2:45 p.m. in the ER revealed:
*One of two ER bed mattresses had a rip in the vinyl cover approximately three inches long that exposed the foam pad. That rip and exposed foam created an uncleanable surface.
*Interview with the director of patient services at the time of the observation confirmed the rip in the ER bed mattress. She stated maintenance was responsible for monitoring equipment.

Review of the AORN 2014 guidelines for Environmental Cleaning, p. 260, revealed:
*"II.h. Mattresses and padded positioning device surfaces (eg. OR beds, arm boards, patient transport carts) should be moisture-resistant and intact. Absorbent or nonintact surfaces may become reservoirs for microorganisms and may harbor pathogens."
*"II.h.1. Damaged or worn coverings should be replaced."

Surveyor: 20031
4. Observation on 6/10/15 from 1:00 p.m. to 1:30 p.m. of the surgical suite revealed a loose stack of tri-fold paper towels laid on the shelf above the two surgical scrub sinks. Directly across from the surgical scrub sinks was a two compartment sink with soap but no paper towels.

Interview with CT A at the time of the observation confirmed that finding. She stated they did not use the two compartment sink for hand washing, so they did not fill that paper towel dispenser. She stated they did not have a paper towel dispenser for the scrub sinks, so she would leave a pile of paper towels for the doctors and nurses to use.

Observation at that same time revealed a rubber hose was directly attached to an outdoor faucet in the wall next to the sink in the scope processing room.

Interview with CT A at the time of the observation confirmed that finding. She stated that faucet was connected to the building's distilled water and was used to rinse the scopes. She was not aware that hose should have a backflow prevention device to ensure the distilled water would not become contaminated.

Review of the 3/2015 dated Environmental Rounds Worksheet revealed:
OR: Furniture clean and in good condition.
OR: Hand towel dispenser available/operable.
ER: Furniture clean and in good condition.

The last completed environmental round worksheets had been in completed in October 2014.

Review of the AORN 2014 guidelines for Hand Hygiene, p. 63-64, revealed:
"II.b.3. Paper towel dispensers should be designed to prevent recontamination when removing towels. The towel dispenser should dispense cleanly without the need to touch the towel dispenser."