HospitalInspections.org

Based on observation, and interview the Hospital failed to consistently adhere to infection control standards for hand hygiene practices, sharps reduction activities and adhering to the manufacturer's guidelines to ensure the effectiveness of high level disinfection of patient care equipment.


Observations in Operating Room (OR) #1 were made by the Surveyor at 8:30 A.M. on 6/23/15. OR #1 was being prepared for an orthopedic procedure. OR Technician #1 dropped an instrument on to the floor and immediately picked it up and disposed of the instrument and continued to open the clean supplies for the upcoming case. OR Technician #1 failed to perform hand hygiene after picking up the instrument dropped on the floor and before handling the clean supplies. Registered Nurse #1 dropped a supply wrapper on to the floor and immediately picked it up and disposed of the wrapper and continued to assist the technician with opening the clean supplies for the upcoming case. Registered Nurse #1 failed to perform hand hygiene after picking up the trash from the floor and before handling the clean supplies.

Observations in the Operating Room Clean Supply storage area were made by the Surveyor at 8: A.M. on 6/23/15. Non-safety 1 cc syringes , 3 cc syringes and boxes of #16, #19, #20, and #30 gauge non-safety needles were readily available for use. The sharps exemption waivers were reviewed at 11:30 A.M. on 6/23/15. The sharps exemption waivers indicated the active safety system (the safety mechanism is activated by the clinician after the injection) was "interfering" with the procedure. However there was no evidence that passive safety system items (the sharp is automatically shielded after use) had been trialed as alternatives.

The Surveyor interviewed OR Technician #1 at 10:30 A.M. on 6/23/15. OR Technician #1 said she used high level disinfection (a chemical process that is designed to eliminate all microorganisms in or on an instrument, except for a small numbers of bacterial spores) to reprocess cystoscopes (an instrument used to visualize the urinary bladder). According to the Manufacturer's directions for use, the chemical solution must be a minimum of 20 degrees Celsius (68 degrees Fahrenheit) to be effective. The Manufacturer also requires the test strips be checked for accuracy using quality assurance testing each time a new bottle is opened. The quality assurance testing required the user to test six test trips in a full strength and half strength chemical solution. OR Technician #1 said these two steps were not included in her high level disinfection reprocessing program.