HospitalInspections.org

Based on observation, interview and document review, the following lapses in infection control practices were identified in the hospital's radiology department. (1) Staff did not cleanse the septum of medication vials prior to withdrawal of medication in 1 of 1 observations. (2) Staff did not perform hand hygeine prior to applying sterile gloves in 2 of 2 observations. (3) Used syringes were not properly discarded in 1 of 1 observations. (4) Needles used in 1 of 1 radiological procedures lacked safety engineered devices (safety needles). These lapses could increase the potential for infection and exposure to blood borne pathogens.

Findings regarding (1) include:

-- During observation on 9/18/18 at 11:30 am, Staff A, Radiology Technologist (RT) and Staff B, RT prepared medications for an arthrogram and did not use an alcohol prep pad to cleanse the rubber septum of several medication vials after opening the vials and prior to needle insertion to withdraw medication. This finding was acknowledged by Staff A and Staff B at the time of observation. Staff A indicated they never cleanse the septum on a newly opened vial.

-- Review of the facility's policy and procedure (P&P) titled "Medical Imaging Department Infection Control," last reviewed 10/2017 revealed, it did not instruct staff to cleanse the rubber septum on medication vials after opening the vials and prior to needle insertion to withdraw medication

-- Review of APIC: (Association for Professionals in Infection Control and Epidemiology) Safe Injection, Infusion and Medication Vial Practices in Health Care (2016) indicated to disinfect the rubber stopper of medication vials with sterile 70% alcohol before inserting a needle.

Findings regarding (2) include:

-- During observation of a shoulder arthrogram on 9/18/18 at 11:50 am, Staff C, Radiologist and Staff D, Physician's Assistant entered the procedure room and applied x-ray aprons and thyroid collars (both act as a radiation shield) and then applied sterile gloves. Neither staff performed hand hygeine before applying sterile gloves.

-- During interview of Staff C on 9/18/18 at 1:05 pm, he/she acknowledged the above findings.

Findings regarding (3) include:

-- During observation on 9/18/18 at 12:10 pm, Staff D discarded syringes containing medications into a non-regulated medical waste receptacle.

-- Review of the facility's P&P titled "Medical Imaging Department Infection Control," last reviewed 10/2017 indicated, all needles and syringes shall be placed in a sharps container.

-- During interview of Staff E, Medical Imaging Department Manager on 9/18/18 at 1:30 pm, he/she acknowledged the above finding.

Findings regarding (4) include:

-- During observation of a shoulder arthrogram on 9/18/18 at 11:50 am, Staff C detached contaminated needles from medication syringes with his/her gloved hands, no safety devices were present (e.g., sharps container, shielded needle devices, etc.). At the completion of the procedure Staff D picked up multiple contaminated exposed needles with his/her gloved hands and walked across the room to place in the sharps container.

-- During interview of Staff E on 9/18/18 at 1:30 pm, he/she acknowledged the above findings.