HospitalInspections.org

Based on record review and interview the facility failed to ensure reserialization of scopes and implement consistency of documentation for tracking endoscope sterilization to the patient. This failed practice placed all patients at risk for infection transmission due extended hang time of scopes between cleaning and documentation that did not ensure sterilization had been met. Findings:


Review of the sterilization envelope dated 8/29/18 revealed 2 cycles had been completed; #3010 the diagnostic and #3011. The documentation on the envelope did not identify the scope number, who released the load, or a patient identifier. Inside the envelope were 3 sterilization strips. Cycle #3010 was the diagnostic and cycle #3012 had not identifying information on the strip. Cycle #3011 was missing. In addition there was a strip dated 8/29/18 for cycle #3745 in the envelope, again with no identifying information.

Review of the sterilization envelope dated 8/31/18 revealed 2 cycles had been completed; #3746 the diagnostic and #3747 a "bronchoscope." The envelope did not identify the scope number, who released the load or a patient identifier. Inside the envelope was a scope cleaning tag dated 8/10/18. The scope should have been re-sterilized before use due to the hang time of greater than 5 days per the facility policy.


Review of the facility policy "OR-018 Cleaning, Disinfecting, Sterilizing, or Storing of Instruments," revised 3/24/17, revealed "All endoscopes will be reprocessed after each procedure and before use if unused for more than 5 days."