HospitalInspections.org

Based on observation, staff interview and document review, the hospital's infection control officer failed to develop systems and an active infection control program that ensured all hospital personnel followed basic infection control practices during one of one observation of staff cleaning a patient room after the patient had been discharged. The failure of implementation of a system to minimize the spread of infectious microorganisms potentially can result in the spread of infections from one patient to another and from one discharged patient to a newly admitted patient.

Findings included:

- Review on 5/10/10 of the "Virex II 256" manufacturer's guidelines for disinfection instructed staff to leave "Virex II 256" on surfaces for 10 minutes to assure disinfection.

- Review on 5/10/10 of the directions on the "Clinging Toilet Bowl " directed, " ...cleans and disinfects in one minute...Remove water from bowl...pour 1 ounce of product onto applicator...scrub entire unit especially under the rim at water outlet, wait 1 minute, then flush..."

- Observations on 5/10/10 from 3:25pm to 4:40pm of the terminal cleaning of room #8 following the discharge of a patient revealed staff B used the hospital-approved disinfectant " Virex II 256" to clean the room. Staff B used a cleaning cloth saturated with the disinfectant to clean a green chair in the room. The surface remained visibly wet for approximately 7 minutes not the required 10 minutes for total disinfection. Staff C used the hospital approved toilet bowl cleaner "Clinging Toilet Bowl" from a squirt bottle in the toilet bowl around the rim and into the water. Staff C stated they "just put some in under the rim." Staff C then sprayed "Virex II 256" on the surfaces of the shower and rinsed off the shower surfaces with water after 3 minutes not the required 10 minutes for total disinfection. Staff C returned to clean the toilet and brushed the inside of the toilet bowl with a toilet bowl brush. Staff C failed to remove the water from the toilet bowl before cleaning the toilet with "Clinging Toilet Bowl" cleaner to achieve the desired disinfection of the toilet bowl.

At 4:05pm staff B removed their gloves and left the room. At 4:08pm staff B returned to the room and put on gloves to resume cleaning. The staff member failed to perform hand hygiene after they removed their gloves and when they return to the room.

Administrative staff A observed the cleaning of room #8 on 5/10/10 between 3:25pm and 4:40pm and acknowledged the green chair and shower surfaces failed to remain wet with "Virex II 256" for the manufacturer required 10 minutes. Staff A, staff B and staff C on 5/10/10 at 3:30pm acknowledged they were unaware they needed to remove the water from the toilet bowl before applying "Clinging Toilet Bowl", clean the toilet bowl, wait one minute and then flush the toilet.

- Observation on 5/11/10 at 10:15am of the daily cleaning of patient room #6 revealed staff B used the hospital approved disinfectant "Virex II 256" to clean the room. Staff B used a cleaning cloth saturated with the disinfectant to clean the sink and counter area. The surface remained visibly wet for approximately 7 minutes not the required 10 minutes for total disinfection.

Staff B on 5/11/10 at 10:32 acknowledged the sink and counter failed to remain wet with "Virex II 256" for the manufacturer required 10 minutes.





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