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Based on review of documentation and interviews, it was determined that the Hospital failed to ensure there was a written plan for tracking the performance of endoscope cleaning to ensure that adherence to cleaning/disinfection procedures were sustained after the completion of six random monitoring checks.

Findings include:

1) Review of documentation indicated that all Central Processing Department (CPD) Staff had received education related to scope cleaning procedures as a result of the incident involving Patient #1 when a hysteroscope that had retained tissue from another patient in one of the channels was utilized.

2) Review of documentation indicated in response to the incident six monitoring check of processed/cleaned scopes had been scheduled for performance between September 26, 2011 and December 5, 2011.

3) The Director of CPD (Director) was interviewed in person on 10/19/11 at 10:45 am. The Director said she was performing the random monitoring of scopes and procedure kits once they had been processed to ensure, among other things, they were cleaned appropriately. She said she has already completed three of the six monitoring check and had not identified any issues. She said once the six planned monitoring checks were completed there was no formal plan or schedule in place for ongoing scope monitoring.

Based on observations made in the Central Processing Department, it was determined that the Hospital failed to ensure equipment was stored in an area that would minimize the risk of contamination.

Findings included;

During a tour of the Central Processing Department conducted on 10/19/11 at 9:30 A.M, it was observed that there were several areas of water stains visible on ceiling tiles. In addition, the door to the Director's office located adjacent to the clean/sterile instrument packs was kept open with a door stop.

Based on review of documentation and interviews, it was determined that the Hospital failed to ensure there was a written plan for tracking the performance of endoscope cleaning to ensure that adherence to cleaning/disinfection procedures were sustained after the completion of six random monitoring checks.

Findings include:

1) Review of documentation indicated that all Central Processing Department (CPD) Staff had received education related to scope cleaning procedures as a result of the incident involving Patient #1 when a hysteroscope that had retained tissue from another patient in one of the channels was utilized.

2) Review of documentation indicated in response to the incident six monitoring check of processed/cleaned scopes had been scheduled for performance between September 26, 2011 and December 5, 2011.

3) The Director of CPD (Director) was interviewed in person on 10/19/11 at 10:45 am. The Director said she was performing the random monitoring of scopes and procedure kits once they had been processed to ensure, among other things, they were cleaned appropriately. She said she has already completed three of the six monitoring check and had not identified any issues. She said once the six planned monitoring checks were completed there was no formal plan or schedule in place for ongoing scope monitoring.

Based on review of documentation and interviews, it was determined that the Hospital failed to ensure there was a written plan for tracking the performance of endoscope cleaning to ensure that adherence to cleaning/disinfection procedures were sustained after the completion of six random monitoring checks.

Findings include:

1) Review of documentation indicated that all Central Processing Department (CPD) Staff had received education related to scope cleaning procedures as a result of the incident involving Patient #1 when a hysteroscope that had retained tissue from another patient in one of the channels was utilized.

2) Review of documentation indicated in response to the incident six monitoring check of processed/cleaned scopes had been scheduled for performance between September 26, 2011 and December 5, 2011.

3) The Director of CPD (Director) was interviewed in person on 10/19/11 at 10:45 am. The Director said she was performing the random monitoring of scopes and procedure kits once they had been processed to ensure, among other things, they were cleaned appropriately. She said she has already completed three of the six monitoring check and had not identified any issues. She said once the six planned monitoring checks were completed there was no formal plan or schedule in place for ongoing scope monitoring.