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Based on facility tour, staff interviews, and review of the facility's policies/procedures, the facility failed to be in compliance with its policies and did not adequately maintain infection control processes within the Pediatric Post Anesthesia Care Unit. The failure created the potential for a negative patient outcome.

The findings were:

Tour of the facility's Post Anesthesia Care Units (PACU) was conducted on 9/29/2010 at approximately 8:50 a.m. Tour of the pediatric specific PACU revealed a cool mist aerosol bottle connected to the oxygen regulator as well as long blue tubing attached, which would then connect to some type of patient mask. The water reservoir/bottle was labeled 9/25. When the PACU Charge Nurse was inquired about the water reservoir, she stated that the bottles are dated and changed once a week. Further interview revealed that the blue tubing is changed for every patient, as well as the patient's mask. The PACU manager stated that the affiliated pediatric hospital does the same practice and s/he stated that it is "standard of practice."

In an interview with the Director of Infection Control on 9/29/2010 at approximately 11:45 a.m., s/he stated that the facility has not had any known respiratory infection transmissions between pediatric non-ventilated surgical patients. The Director stated that s/he could do some cultures to determine if microorganisms are transmitted back into the bottle/reservoir.

In an interview with the Manager of Respiratory on 9/29/2010 at approximately 12:15 p.m., s/he stated Respiratory Therapists do not routinely go to the PACU unless they are called there for a specific need. S/he stated that s/he did not know that the cool mist aerosol bottles were kept on for multiple days. In discussing infection control issues, s/he stated that due to the short amount of time the pediatric post-surgical patients use the cool-mist and due to the cool temperature, it would be unlikely to cause much condensation that would enter back into the bottle/reservoir. However s/he also stated, "Standard of practice is not to use multi-use respiratory supplies." Additionally, s/he stated that literature does not support that cool-mist helps with pediatric surgical patients.

On 9/29/2010, the facility's policy titled "Infection Control/Equipment Processing Policy for Respiratory Services," dated 8/2010, was reviewed. It stated the following, in pertinent part:
"Respiratory care division will follow Memorial Hospital's infection prevention program and policies to provide our patients with a safe environment; minimize the risk of infection and transmission of communicable disease... 2. Respiratory circuits and patient supplies: A. Every patient started on therapy will receive a clean, disinfected price of equipment. Equipment will be assembled and checked for proper operation before going to the patient's room. All disposable equipment will be single-patient use. Disposable equipment must never be cleaned or re-sterilized for re-use... E. Aerosol-producing equipment will be changed every 48 hours or if grossly contaminated. Equipment will be labeled with date and time changed..."