HospitalInspections.org

27137

Based on observation, interview, and record review, the infection control officer failed to develop and implement effective systems for identifying, investigating, and controlling potential infections in accordance with the hospital policy and procedures, and nationally recognized infection control guidelines, as evidenced by the hospital's failure to ensure:

1. Three of four licensed nurses interviewed were trained and competent to effectively disinfect shared patient glucometers (a handheld electronic device used to measure the amount of sugar in a drop of blood), devices that are potentially exposed to blood borne infectious agents, and,

2. Endoscopes (long, flexible, tube-like devices used to visually examine, diagnose, and treat diseases of the intestinal tract) were processed and stored according to nationally accepted infection control guidelines and manufacturer's recommendations when the endoscopes:

a) were not flushed with alcohol and dried with compressed air, and,
b) were stored in an enclosed cabinet in a vertical position,

3. Staff were trained and competent to effectively clean and disinfect high touch areas in the hospital's Emergency Department.

These findings had the potential to contribute to the spread of infection(s), or infectious agents, in the hospital.

Findings:

1. During an interview with Registered Nurse (RN) 4 on 1/22/14, at 10:45 AM, in the perioperative area, she indicated the shared glucometer was cleaned/disinfected with the "Super Sani-cloths" located in the purple top canisters. When asked what the kill time was and what kill time meant, RN 4 indicated the kill time was three minutes, and it meant after the surface had been wiped with the cloth, nothing could be set on that surface for three minutes. When asked what should be done if the surface(s) of the glucometer dried before the kill time, RN 4 stated, "I would assume its okay."

During an interview with RN 1 on 1/23/14, at 9:35 AM, she stated she cleaned the shared glucometer with the Super Sani-cloths located in the purple top canisters. When asked what the kill time for the cloths were, RN 1 stated it was three minutes. When asked what should be done if the surface(s) of the glucometer dried before the kill time, RN 1 stated, "Clean it again? I'm not sure but I can find the answer for you."

During an interview with RN 3 on 1/23/14, at 10:25 AM, he stated he cleaned the shared patient glucometer after each use with 70% alcohol pads. RN 3 stated he cleaned the glucometer screen but did not clean that part of the glucometer where the strip with the drop of blood was inserted because that would affect the reading.

Online review of the manufacturer's instructions for use indicated the Super Sani-Cloth used in the hospital has a two minute kill time (this is the time surfaces must remain visibly wet with the product to kill the potentially infectious agents).

2a. During an observation in the decontamination room of the Diagnostic Treatment Center (DTC), on 1/22/14, at 12:10 PM, Technician (Tech) 1 was observed removing an endoscope from an automatic endoscope reprocessing (AER) machine and attaching the scope to a suction machine with a setting of continuous low suction. In a concurrent interview, Tech 1 was asked about this process and she indicated the hospital's procedure was to remove remaining fluids in the endoscope after it had completed processing in the AER by attaching the scope to the suction machine. When asked if the scopes were flushed with alcohol to facilitate drying, Tech 1 stated, "We used to do an alcohol flush but we stopped about two years ago."

When asked if she was concerned the suctioning action could draw water back up into the endoscopes channels, where it could potentially provide a medium for microorganism growth, Tech 1 said, "I just never thought of that."

During an interview on 1/23/14, at 1:40 PM, with the Infection Control Preventionist (ICP) 1, she stated she had contacted the manufacturer of the hospital's endoscopes, (Olympus), who stated they always recommend their endoscopes be flushed with alcohol to facilitate drying. ICP 1 confirmed it was the hospital's policy to follow the manufacturer (Olympus) and AORN (Association of Operating Room Nurses) standards/recommendations for endoscope processing and storage.

A review of the fax provided on 1/24/14 from the hospital to the survey team leader was conducted. The fax included the written manual endoscope processing instructions from Olympus. Under the instructions on page 4 of the fax under the heading "Rinse the endoscopes and accessories" the following information was provided: "Flushing the interior and recessed parts of the endoscope and accessories with alcohol facilitates drying. Olympus recommends the use of alcohol."

A review of the 2012 AORN Standards and Recommended Practices, under "Recommended Practices for Cleaning and Processing Flexible Endoscopes and Endoscope Accessories", was conducted with ICP 1 on 1/23/14 at 1:45 PM. The following information related to drying and storage of endoscopes was provided: "Flexible endoscopes should be cleaned and stored in accordance with the manufacturer's written instructions. Failure to follow the manufacturer's written instructions could result in ineffective cleaning that interferes with high-level disinfection or sterilization, creating a risk of infection for the patient.

After high-level disinfection, flexible endoscopes should be rinsed and the internal channels flushed with water (e.g., sterile water, filtered or unfiltered tap water) followed by a 70% to 90% ethyl or isopropyl alcohol rinse and flush, unless contraindicated by the manufacturer's written instructions. Rinsing with alcohol assists with removing the water because the alcohol binds with the water remaining in the channel, facilitating the drying process and killing any microorganisms contained in the water.

After rinsing with 70% to 90% ethyl or isopropyl alcohol, the channels should be dried using low pressure forced air. Using forced air assists with removal of moisture remaining in the channels. Dry air channels do not support microbial growth. In a concurrent interview, ICP 1 acknowledged AORN and Olympus standards recommended flushing the endoscope with alcohol after rinsing to facilitate drying, and drying the endoscope channels using low pressure forced air.

2b. During an observation on 1/22/14, at 12 PM, ten endoscopes were observed lying flat and individually packaged coiled inside large plastic containers with lids. The scopes in their containers were stacked on a table located inside decontamination room of the DTC endoscopy area. In a concurrent interview with Tech 1, she stated the scopes were only temporarily being stored in the containers. Tech 1 stated they were to be taken down to be hung in the endoscope storage cabinet. When asked how long they would remain in the plastic containers, Tech 1 stated anywhere from two minutes to ten minutes at the longest.

At 12:30 PM, the same ten endoscopes were observed still lying flat in their plastic containers. In a concurrent interview with the Registered Nurse Clinical Supervisor (RNCS), when asked how long the endoscopes would be stored flat coiled in the plastic containers, she replied, "I don't know if we have a time limit. Most times the scopes are moving continuously. Today we have a gap."

On 1/23/14 at 1:40 PM, ICP 1 confirmed it was the hospital's policy to follow the manufacturer (Olympus) and AORN standards and recommendations for endoscope storage.

In an interview on 1/23/14, at 1:40 PM, ICP 1 indicated she spoke to an Olympus representative, who recommended the endoscopes be stored hanging vertically.

A review of the 2013 AORN Standards and Recommended Practices, under "Recommended Practices for Cleaning and Processing Flexible Endoscopes and Endoscope Accessories", was conducted and provided the following information: "When flexible endoscopes are hung in the vertical position, coiling or kinking is prevented, allowing any remaining moisture to drain out of the endoscope and decreasing the potential development of an environment conducive to microbial growth in the endoscope. Proper storage facilitates drying and decreases potential for contamination. Opening all valves and removing all accessories facilitates drying. The scope protector may create an environment favorable for microbial growth if the flexible endoscope is not dry and cannot hang straight."

3. During an interview with Environmental Services Worker (EVS) 1 on 1/23/14, at 11:10 AM, in the Emergency Department, she indicated she cleaned high touch surfaces in the emergency room area, such as bed rails, doorknobs, and counter surfaces with a disinfectant called "HDQL". When asked what the kill time for the HDQL disinfectant was, EVS 1 stated it was ten minutes. When asked what should be done if the surface(s) dried before the kill time of ten minutes, EVS 1 stated, "You got me on that one, I'm not sure." EVS 1 indicated she had worked for the hospital in housekeeping for five years.

During a review of the product information for "Super HDQL10", it read under "Directions For Use" that surfaces are to "Allow to remain wet for ten minutes, then remove excess liquid."