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Based on record review, interview, and policy review, the provider failed to ensure two of three sampled patients (20 and 21) who had blood transfusions had complete documentation of the blood administration. Findings include:

1. Review of patient 20's 8/26/15 admission medical records revealed he had received six units of packed red blood cells (PRBC). Four of the six blood administration documents had missing dates, times, and signatures as follows:
*On 8/26/15 at 8:08 p.m. a unit of blood was started. A signature, date, and time was missing from the patient identity confirmation for the second registered nurse (RN). A signature, date, and time was missing from when the transfusion had been completed.
*On 8/26/15 at 9:04 p.m. a second unit of blood was completed. A signature, date, and time was missing from when the transfusion had been completed. The transfusion record stated "See PACU [post anesthesia care unit] flowsheet.
-Review of the PACU flowsheet revealed no vital signs past 8:30 p.m. and no documentation of the second unit of blood having been started. The note section revealed "Order for 2u [units] prbc's to be given." "Blood transfusion began to peripheral Rt. [right] hand 18 g [gauge] IV [intravenous] w/ [with] NS [normal saline] IVF [intravenous flush] to Groshong [implanted venous access device] port per access" "Blood units hand squeezed per ___ [physician's name]" "After 2nd unit of blood infused, BP [blood pressure] elevates to acceptable level."
*On 8/27/15 at 8:40 a.m. a unit of blood was started. A time was missing from when the transfusion had been completed.
*On 8/27/15 at 3:15 p.m. a unit of blood was started. A time was missing from when the transfusion had been completed.

2. Review of patient 21's 6/8/15 admission medical record revealed she had received two units of PRBCs. One of the two blood administration documents was missing a signature, date, and time for the second staff signature for the blood product check out from the blood bank.

3. Interview on 9/9/15 at 3:00 p.m. with the chief nursing officer confirmed the above missing signatures, dates, times, and vital signs. She agreed the forms had not been filled out according to the provider's policy and procedure.

Review of the provider's revised 7/21/15 Blood Administration policy revealed:
*"Two BHSH [Black Hills Surgical Hospital] staff (2 nurses or 1 nurse and 1 laboratory technician) are required to confirm identification of patient and donor unit and then check the blood unit out of the Blood Bank for transfusion." "Date and time unit was checked out will be recorded."
*"Nursing personnel administering the blood transfusion must correctly identify the patient and the assigned units of blood. Two nursing personnel, one of which signed out the blood product from the Blood Bank, shall verbally verify (read aloud) the information below and document verification at the bedside immediately prior to starting the transfusion."
*"Document the time that the transfusion started and the time the transfusion ended on the 'Transfusion Record' area of the Product Request Form."
*"After the first 15 minutes of the transfusion, the patient's vital signs shall be rechecked and documented on the Product Request Form."
*"Recheck temperature and BP [blood pressure] as per protocol during the transfusion."
*Upon completion of the transfusion, document the time that the transfusion ended on the Product Request Form."

A. Based on random observation, manufacturer's guidelines review, record review, interview, and policy review, the provider failed to ensure a sanitary environment was maintained or achieved for the following items and/or areas throughout the facility and two or two outbuildings:
*Disinfectant expiration dates were not monitored to ensure the effectiveness of the bleach wipes for the re-usable patient glucometer.
*Correct contact time for the phenol (Hil-Phene) disinfectant was not followed for:
-The post anesthesia care unit (PACU) and patient bays within the unit.
-The clean and dirty totes used to transfer surgical instruments to and from the off-site central sterilization (CS).
-The carts in the off-site CS garage.
*The wet wiping cloth buckets used for the Hil-Phene were not dated with an expiration date.
*There was no way to check the effectiveness of the Hil-Phene.
*The disinfectant used throughout the facility and its outbuildings was not effective against methicillin resistant staphylococcus aureus (MRSA) and methicillin sensitive staphylococcus aureus (MSSA).
*An approved disinfectant was not used for the assembly tables at the off-site CS.
*Assembly table mats at the off-site CS were frayed and torn along the edges.
*A set procedure and guideline was not used for mixing the Hil-Phene in the mop buckets for the floors at the off-site CS.
*The correct mixing procedure for bleach was not used for disinfection of all patient room bathrooms.
*Thirty-nine hinged surgical instruments were not sterilized in the open position at the on-site CS.
*Four of ten Stryker patient beds in the PACU did not have a durable and cleanable surface.
*The van used to transport soiled and dirty items was not cleaned and disinfected before the transportation of clean supplies and instruments.
Findings include:

1. Observation and interview on 9/8/15 at 10:30 a.m. with registered nurse (RN) E revealed a container of Micro-Kill Bleach wipes on the nursing station counter in the pre-operative area. Those wipes had an expiration date of July 2015. RN E stated those wipes were used on the glucometer between patient use.

2. a. Observation and interview on 9/8/15 at 10:30 a.m. with RN H revealed:
*She was wiping down a post-operative bed in PACU using a disposable wipe.
*The surface of the bed mattress and side rails remained wet for approximately three minutes.
*She stated the wipe was from a bucket that was labeled Hil-Phene.
*There was no information on the bucket of Hil-Phene for how long it was to have stayed wet to have been effective.
*She was not sure of how long the Hil-Phene needed to stay wet on a surface to be effective.
*There was no date on the bucket to indicate when the solution had been mixed.

Interview on 9/8/15 at 3:55 p.m. with the chief operating officer (COO) revealed all employees should have known how long the contact time was for Hil-Phene. He stated that was accomplished through training and the policy for all employees to follow.

b. Interview on 9/9/15 from 2:50 p.m. through 3:30 p.m. with CS technician F revealed:
*Soiled and contaminated surgical instruments were transported in red totes from the main hospital to the CS building.
*They were unloaded into the garage and then immediately into the decontamination room of CS.
*After the totes were emptied they were placed one-by-one in a deep sink.
-They were sprayed inside and outside with a mixture of Hil-phene and water. That mixture was two pumps of the Hil-phene into a one and one-half quart spray bottle that was then filled with water.
-The red totes would then sit wet for five minutes.
-After the five minute set time they were sprayed off with water and they were placed on a metal shelf to dry.
*She was not aware the Hil-Phene required at least a ten minute wet contact time to have been effective.

Additional observation at that same time of the garage area also noted enclosed stainless steel carts.
*CS technician F stated those carts were used to transport the clean and sterilized instruments back to the hospital.
*She stated the night shift cleaned and disinfected the enclosed stainless steel carts with the Hil-Phene spray bottle mixture. They then left them to dry in the garage.

Review of the provider's 8/18/14 Cleaning and Decontamination Processes policy revealed:*"Red totes used to transport contaminated sets shall be thoroughly rinsed with water."
*"Sprayed with a disinfectant solution, and allowed to air dry prior to reuse."
*Education and competency would have included the application and use of chemical disinfectants.

3. Random observation from 9/8/15 through 9/9/15 revealed every department or area of the hospital, medical imaging center, and off-site CS facility had a Wet Task bucket. Those buckets had a label that identified the solution in the bucket. However those buckets were not dated with the mix date or the date the solution expired. One bucket of solution in the imaging center had been dated 3/14/15. Six other buckets of solution at the imaging center had no dates.

Interview at the time of the observations with the COO revealed he was not aware those buckets of disinfectant solution should have been dated.

Interview on 9/8/15 at 3:30 p.m. with employee J revealed she had contacted the sales person for the disinfectant. He stated the mixed solution was good for thirty days after it was mixed.

Review of the fact sheets for Hil-Pheen revealed the product was effective for twenty-eight days after dilution. The directions for use stated:
-The surface must be cleaned of soil and filth.
-Then apply the mixed solution of Hil-Phene to the surface area so as to wet the surface thoroughly.
-The area was to remain wet for ten to fifteen minutes depending on the pathogen or fungi.

There was no direction or guideline in the cleaning policy for dating the disinfecting solution once it was mixed.

4. Review of the Hil-Phene specification sheets and guidelines revealed there was no way to test the efficacy of the solution.

Interview on 9/8/15 at 3:30 p.m. with employee J revealed she had contacted the sales person about the disinfectant. He stated there was no testing system to ensure the correct ratio of the disinfectant to water for the Hil-Phene solution.

5. Review of the past surgical infection control tracker for 2014 and through the current month of 2015 revealed the facility had:
*2014: One case of MRSA and one case of MSSA.
*2015 to current month: Two cases of MRSA and three cases of MSSA.

All of the areas associated with the operating suite were disinfected with Hil-Phene and included all:
*Pre-operative rooms,
*Operating rooms,
*Dirty and clean rooms for sterilization,
*Clean supply rooms, and
*Post-acute care unit rooms.

Review of the Hil-Phene specific manufacturer instructions and guidelines revealed the product was not effective against MRSA or MSSA.

Interview on 9/9/15 at 7:20 a.m. with employee J revealed she had retrieved data from the Internet to show a phenol disinfectant was effective against MRSA and MSSA. She had no data to show the Hil-Phene product itself was effective against those infections.

6. Observation and interview on 9/9/15 from 2:50 p.m. through 3:30 p.m. with CS technician F revealed:
*The CS floors were cleaned and disinfected with Hil-Phene.
*The mixture was three and one-half ounces of the Hil-Phene and then water added up to the second mark on the mop bucket.
*She was unsure of how much water was added or if the strength was accurate.
*She went by the instructions she had been given.
*Those instructions were posted on the wall next to the sink used to wash the red totes.

7. Observation on 9/9/15 at 2:45 p.m. of the CS area clean room revealed:
*Six work stations.
*Those work stations were stainless steel tables used to assemble surgical packets for sterilization.
*On the tables were thin plastic mats with a thin rubber cushion on the bottom.
*Those mats had frayed edges making them uncleanable.

Interview with CS technician F revealed those mats were cleaned before and after each shift.

Interview on 9/9/15 at 2:50 p.m. with CS technician F revealed those mats and the stainless steel assembly tables were cleaned before and after each shift. They were cleaned by using 70% isopropyl alcohol put on cloths. She was not aware if the alcohol was an appropriate disinfectant or not. She stated that was what had always been used.

8. Observation on 9/8/15 at 1:30 p.m. revealed a housekeeping cart with supplies with a squirt bottle labeled "bleach." The color of the liquid in the bottle appeared to be full strength bleach. Interview with the COO at the time of the observation confirmed that finding. He stated all housekeeping carts should have a squirt bottle of bleach to mix with water to disinfect all the patient bathrooms. He stated it was done per policy and procedure to kill Clostridium Difficile (C. diff.).

Review of the Terminal Cleaning of Patient Suites policy dated 6/22/15 revealed:
*"2. Bathroom cleaning
-Using a 4:1 [4 cups of bleach to 1 cup of water] bleach concentration soaked cloth, wipe all surfaces in the bathroom area: door,...
-Window cleaner is used on all mirrors, metal, and shiny finishes (sink area) to polish after disinfected with a 4:1 bleach concentration.
-Use 4:1 bleach concentration water to mop bathroom floor.

During an interview on 9/8/15 at 4:30 p.m. with employee J she was asked if the information in the above policy was correct as the directions in that policy were not in accordance with the Centers for Disease Control (CDC) guidelines. She stated she had taken the guidelines from the CDC website itself. It was pointed out to her the bleach concentration at 4:1 would leave a residue on the surface that could cause a burn, irritation hazard, or be poisonous from contact or inhalation to patients and employees.

Interview on 9/9/15 at 7:30 a.m. with employee J revealed she had checked the CDC website again and found the bleach and water ratio was wrong. She stated she had corrected the policy to read a 1:10 ratio of bleach and water.

9 Observation on 9/9/15 at 9:30 a.m. revealed there were carts with sterilized instruments within the clean supply room within the operating suite. Inspection of the those sterilized instruments revealed thirty-nine hinged instruments (bandage scissors, scissors, and bone clamps) were in the closed position. Interview with employees B and D at that same time confirmed that finding. Employee D stated all staff were aware and had been trained all hinged instruments were to remain open during sterilization. She revealed they used Association of Perioperative Registered Nurses (AORN) and Association for the Advancement of Medical Instrumentation (AAMI) for the policy and procedure for sterilization.

Review of the AAMI 2012 guidelines for Sterilization Processing revealed: "The scrub person should ensure that hinged instruments are open for proper cleaning. When packaging instruments, be sure to select an appropriate size pouch and to place hinged instruments in an open position to allow sterilant contact."

10. Observation on 9/9/15 at 10:15 a.m. revealed four older Stryker patient beds in the PACU. The push bars on the end of those beds had chips and scratches in the paint the size of quarters and dimes. Interview with employee J at the time of the observation confirmed those findings. She agreed that surface was not a durable cleanable surface and could continue to chip.

There was no policy or guideline to indicate who or how often patient care equipment was checked for any needed repairs.

11. Interview on 9/8/15 at 3:30 p.m. with employee J revealed the provider primarily used AORN, CDC, AAMI , and their hospital infection control guidelines for policies and procedures.

Review of the AORN 2014 guidelines for Environmental Cleaning, pp. 259-264, revealed:
*"Equipment that is difficult to clean may harbor pathogens in crevices that are not amendable [responsive] to disinfection."
*"Disinfectants would be applied and reapplied as needed, per manufacturer's instruction, for the dwell [contact] time required to the kill the targeted organism."
*"All floors in the perioperative and sterile processing areas should be disinfected."



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12. Interview on 9/10/15 at 9:15 a.m. with RN J revealed clean and dirty surgical instruments were transported separately. There were two different vehicles used to transport items.

Interview on 9/10/15 at 11:15 a.m. with purchasing assistant/delivery driver I revealed:
*There was only one transport vehicle. That vehicle was used to transport:
-Red totes that contained the contaminated surgical equipment.
-Enclosed stainless steel carts that contained sterilized surgical equipment.
-Medical supplies.
*He stated he only transported the red totes and medical supplies.
*He made eight or nine trips a day.
*He did not clean or disinfect the cargo bay of the van after transporting the red totes.
*He used to spray it down but in the winter it would freeze to the floor.
*He also used to spray it down with Hil-Phene, but the chemical smell was too strong when driving. He had used Clorox wipes, but they had left a white film on everything.
*He did not have any personal protective equipment (PPE) such as gloves or aprons to use when transporting the contaminated surgical instruments.

Review of the provider's 8/18/14 Transportation of Contaminated Items policy revealed:
*"Items contaminated during patient care should be efficiently and safely transported from the point of use to the decontamination area in a manner that prevents exposure or cross contamination of bio hazardous materials, potentially infectious organisms or materials, and/or damage to equipment or instrumentation."
*"Contaminated instrumentation shall be moved offsite to the Lombardy complex via the warehouse transport vehicle."
*"Clean and sterile items should be completely separated in a manner that prevents the possibility of cross-contamination when transported with contaminated items."
*"Transport personnel shall wear PPE as appropriate when handling red bins."
*"Transport vehicle shall be decontaminated by wiping all surfaces with a Hil-Phene solution soaked cloth per manufacturer's instructions for use, prior to loading of sterile and clean items from the Lombardy complex for transport back to BHSH [Black Hills Surgical Hospital]."

B. Based on observation and interview, the provider failed to ensure one of two registered nurses (RN) G followed infection control practices during one of one observed medication pass for one of one observed patient (35). Findings include:

1. Observation and interview on 9/9/15 from 7:40 a.m. through 8:00 a.m. with RN G providing medications to patient 35 revealed:
*She took the patient's 35 medications out of the bin.
*Those medications included a packet of Miralax (laxative) powder and a unit dose package of Allegra (allergy).
*She took a disposable water cup and then into that cup placed:
-The packet of Miralax, a smaller medication cup with the unit dose package of Allegra, a straw, a spoon, and a syringe that contained normal saline.
*She then took out the syringe as she stated she did not need it.
*She carried the cup to patient 35's room.
*She emptied the cup of its contents on the bedside computer shelf.
*She opened the unit dose of Allegra and placed it in the small medication cup and gave that to the patient.
*She opened the package of Miralax powder into the cup and filled it with water from the sink, stirred it with the spoon, placed the straw in the cup and gave it to the patient.
*RN G stated she had not thought the medication packets, spoon, straw, and the syringe could have been contaminated from previous staff touching them. She agreed those items contaminated the inside of the cup and spoon.

Based on record review, interview, and policy review, the provider failed to ensure two of three sampled patients (20 and 21) who had blood transfusions had complete documentation of the blood administration. Findings include:

1. Review of patient 20's 8/26/15 admission medical records revealed he had received six units of packed red blood cells (PRBC). Four of the six blood administration documents had missing dates, times, and signatures as follows:
*On 8/26/15 at 8:08 p.m. a unit of blood was started. A signature, date, and time was missing from the patient identity confirmation for the second registered nurse (RN). A signature, date, and time was missing from when the transfusion had been completed.
*On 8/26/15 at 9:04 p.m. a second unit of blood was completed. A signature, date, and time was missing from when the transfusion had been completed. The transfusion record stated "See PACU [post anesthesia care unit] flowsheet.
-Review of the PACU flowsheet revealed no vital signs past 8:30 p.m. and no documentation of the second unit of blood having been started. The note section revealed "Order for 2u [units] prbc's to be given." "Blood transfusion began to peripheral Rt. [right] hand 18 g [gauge] IV [intravenous] w/ [with] NS [normal saline] IVF [intravenous flush] to Groshong [implanted venous access device] port per access" "Blood units hand squeezed per ___ [physician's name]" "After 2nd unit of blood infused, BP [blood pressure] elevates to acceptable level."
*On 8/27/15 at 8:40 a.m. a unit of blood was started. A time was missing from when the transfusion had been completed.
*On 8/27/15 at 3:15 p.m. a unit of blood was started. A time was missing from when the transfusion had been completed.

2. Review of patient 21's 6/8/15 admission medical record revealed she had received two units of PRBCs. One of the two blood administration documents was missing a signature, date, and time for the second staff signature for the blood product check out from the blood bank.

3. Interview on 9/9/15 at 3:00 p.m. with the chief nursing officer confirmed the above missing signatures, dates, times, and vital signs. She agreed the forms had not been filled out according to the provider's policy and procedure.

Review of the provider's revised 7/21/15 Blood Administration policy revealed:
*"Two BHSH [Black Hills Surgical Hospital] staff (2 nurses or 1 nurse and 1 laboratory technician) are required to confirm identification of patient and donor unit and then check the blood unit out of the Blood Bank for transfusion." "Date and time unit was checked out will be recorded."
*"Nursing personnel administering the blood transfusion must correctly identify the patient and the assigned units of blood. Two nursing personnel, one of which signed out the blood product from the Blood Bank, shall verbally verify (read aloud) the information below and document verification at the bedside immediately prior to starting the transfusion."
*"Document the time that the transfusion started and the time the transfusion ended on the 'Transfusion Record' area of the Product Request Form."
*"After the first 15 minutes of the transfusion, the patient's vital signs shall be rechecked and documented on the Product Request Form."
*"Recheck temperature and BP [blood pressure] as per protocol during the transfusion."
*Upon completion of the transfusion, document the time that the transfusion ended on the Product Request Form."

A. Based on random observation, manufacturer's guidelines review, record review, interview, and policy review, the provider failed to ensure a sanitary environment was maintained or achieved for the following items and/or areas throughout the facility and two or two outbuildings:
*Disinfectant expiration dates were not monitored to ensure the effectiveness of the bleach wipes for the re-usable patient glucometer.
*Correct contact time for the phenol (Hil-Phene) disinfectant was not followed for:
-The post anesthesia care unit (PACU) and patient bays within the unit.
-The clean and dirty totes used to transfer surgical instruments to and from the off-site central sterilization (CS).
-The carts in the off-site CS garage.
*The wet wiping cloth buckets used for the Hil-Phene were not dated with an expiration date.
*There was no way to check the effectiveness of the Hil-Phene.
*The disinfectant used throughout the facility and its outbuildings was not effective against methicillin resistant staphylococcus aureus (MRSA) and methicillin sensitive staphylococcus aureus (MSSA).
*An approved disinfectant was not used for the assembly tables at the off-site CS.
*Assembly table mats at the off-site CS were frayed and torn along the edges.
*A set procedure and guideline was not used for mixing the Hil-Phene in the mop buckets for the floors at the off-site CS.
*The correct mixing procedure for bleach was not used for disinfection of all patient room bathrooms.
*Thirty-nine hinged surgical instruments were not sterilized in the open position at the on-site CS.
*Four of ten Stryker patient beds in the PACU did not have a durable and cleanable surface.
*The van used to transport soiled and dirty items was not cleaned and disinfected before the transportation of clean supplies and instruments.
Findings include:

1. Observation and interview on 9/8/15 at 10:30 a.m. with registered nurse (RN) E revealed a container of Micro-Kill Bleach wipes on the nursing station counter in the pre-operative area. Those wipes had an expiration date of July 2015. RN E stated those wipes were used on the glucometer between patient use.

2. a. Observation and interview on 9/8/15 at 10:30 a.m. with RN H revealed:
*She was wiping down a post-operative bed in PACU using a disposable wipe.
*The surface of the bed mattress and side rails remained wet for approximately three minutes.
*She stated the wipe was from a bucket that was labeled Hil-Phene.
*There was no information on the bucket of Hil-Phene for how long it was to have stayed wet to have been effective.
*She was not sure of how long the Hil-Phene needed to stay wet on a surface to be effective.
*There was no date on the bucket to indicate when the solution had been mixed.

Interview on 9/8/15 at 3:55 p.m. with the chief operating officer (COO) revealed all employees should have known how long the contact time was for Hil-Phene. He stated that was accomplished through training and the policy for all employees to follow.

b. Interview on 9/9/15 from 2:50 p.m. through 3:30 p.m. with CS technician F revealed:
*Soiled and contaminated surgical instruments were transported in red totes from the main hospital to the CS building.
*They were unloaded into the garage and then immediately into the decontamination room of CS.
*After the totes were emptied they were placed one-by-one in a deep sink.
-They were sprayed inside and outside with a mixture of Hil-phene and water. That mixture was two pumps of the Hil-phene into a one and one-half quart spray bottle that was then filled with water.
-The red totes would then sit wet for five minutes.
-After the five minute set time they were sprayed off with water and they were placed on a metal shelf to dry.
*She was not aware the Hil-Phene required at least a ten minute wet contact time to have been effective.

Additional observation at that same time of the garage area also noted enclosed stainless steel carts.
*CS technician F stated those carts were used to transport the clean and sterilized instruments back to the hospital.
*She stated the night shift cleaned and disinfected the enclosed stainless steel carts with the Hil-Phene spray bottle mixture. They then left them to dry in the garage.

Review of the provider's 8/18/14 Cleaning and Decontamination Processes policy revealed:*"Red totes used to transport contaminated sets shall be thoroughly rinsed with water."
*"Sprayed with a disinfectant solution, and allowed to air dry prior to reuse."
*Education and competency would have included the application and use of chemical disinfectants.

3. Random observation from 9/8/15 through 9/9/15 revealed every department or area of the hospital, medical imaging center, and off-site CS facility had a Wet Task bucket. Those buckets had a label that identified the solution in the bucket. However those buckets were not dated with the mix date or the date the solution expired. One bucket of solution in the imaging center had been dated 3/14/15. Six other buckets of solution at the imaging center had no dates.

Interview at the time of the observations with the COO revealed he was not aware those buckets of disinfectant solution should have been dated.

Interview on 9/8/15 at 3:30 p.m. with employee J revealed she had contacted the sales person for the disinfectant. He stated the mixed solution was good for thirty days after it was mixed.

Review of the fact sheets for Hil-Pheen revealed the product was effective for twenty-eight days after dilution. The directions for use stated:
-The surface must be cleaned of soil and filth.
-Then apply the mixed solution of Hil-Phene to the surface area so as to wet the surface thoroughly.
-The area was to remain wet for ten to fifteen minutes depending on the pathogen or fungi.

There was no direction or guideline in the cleaning policy for dating the disinfecting solution once it was mixed.

4. Review of the Hil-Phene specification sheets and guidelines revealed there was no way to test the efficacy of the solution.

Interview on 9/8/15 at 3:30 p.m. with employee J revealed she had contacted the sales person about the disinfectant. He stated there was no testing system to ensure the correct ratio of the disinfectant to water for the Hil-Phene solution.

5. Review of the past surgical infection control tracker for 2014 and through the current month of 2015 revealed the facility had:
*2014: One case of MRSA and one case of MSSA.
*2015 to current month: Two cases of MRSA and three cases of MSSA.

All of the areas associated with the operating suite were disinfected with Hil-Phene and included all:
*Pre-operative rooms,
*Operating rooms,
*Dirty and clean rooms for sterilization,
*Clean supply rooms, and
*Post-acute care unit rooms.

Review of the Hil-Phene specific manufacturer instructions and guidelines revealed the product was not effective against MRSA or MSSA.

Interview on 9/9/15 at 7:20 a.m. with employee J revealed she had retrieved data from the Internet to show a phenol disinfectant was effective against MRSA and MSSA. She had no data to show the Hil-Phene product itself was effective against those infections.

6. Observation and interview on 9/9/15 from 2:50 p.m. through 3:30 p.m. with CS technician F revealed:
*The CS floors were cleaned and disinfected with Hil-Phene.
*The mixture was three and one-half ounces of the Hil-Phene and then water added up to the second mark on the mop bucket.
*She was unsure of how much water was added or if the strength was accurate.
*She went by the instructions she had been given.
*Those instructions were posted on the wall next to the sink used to wash the red totes.

7. Observation on 9/9/15 at 2:45 p.m. of the CS area clean room revealed:
*Six work stations.
*Those work stations were stainless steel tables used to assemble surgical packets for sterilization.
*On the tables were thin plastic mats with a thin rubber cushion on the bottom.
*Those mats had frayed edges making them uncleanable.

Interview with CS technician F revealed those mats were cleaned before and after each shift.

Interview on 9/9/15 at 2:50 p.m. with CS technician F revealed those mats and the stainl