HospitalInspections.org

Based on observation, interview, and record review the facility failed to:

1. Maintain the temperature of the high level disinfectant (cleaner that reduces the amount of most harmful organisms) used during the cleaning of transvaginal probes (device that uses sound waves to produce an image of organs within the pelvis). This deficient practice practice may reduce the effectiveness of the disinfectant and lead to transmission of infection.

2. Ensure that IV lines (a soft, flexible tube placed inside a vein, usually in the hand or arm in order to infuse medicine or fluid) were clearly labelled with the date they were initially placed for 2 of 30 Patients (Patient 21 and Patient 17). This deficient practice had the potential to increase inflammation and infection in the vein of the patients.

Findings:

1. During an interview on 4/12/2023 at 10:45 AM, the Radiology Supervisor stated that the minimum temperature for the high level disinfectant used during cleaning of transvaginal probes should be 20 degrees centigrade (68 degrees fahrenheit) and that a log is kept of the solution temperature with each use.

During an interview on 4/12/2023 at 2:30 PM, the Radiology Supervisor revealed that the facility was not correctly monitoring the disinfectant temperature by measuring the ambient (area surround the disinfectant) temperature instead of the temperature of the solution.

During a review of the 'Cidex OPA (high-level disinfectant for reprocessing reusable heat-sensitive semi-critical medical devices such as Transvaginal Probes) Solution Use Log', this document indicated that, during the period beginning 12/5/2021 through 1/6/2022, there were three times when the temperature of the sanitizing solution was below 68 degrees fahrenheit (12/16/2021, 12/28/2021, 12/29/2021) when probes were being disinfected.

During a review of 'How to Use Cidex OP', this document details that all lumens (cavities within the probe) should be filled with this solution. Following total immersion, the instrument should be soaked for 12 minutes at 20 degrees celcius (68 degrees fahrenheit) in order to achieve high level disinfection.


2. During an observation on 4/11/2023 at 2:00 PM of the medical/surgical unit (area where a broad range of acute care patients are housed), Patient 21 had an IV inserted into her left forearm. The entry point of the IV into the skin was marked with an op site (thin plastic dressing to protect from infection) labelled with a date of 3/31/2023. There was no label on the tubing that led to the insertion site into the skin.

During an observation on 4/11/2023 at 11:38 AM of the medical/surgical unit, Patient 17 had an IV inserted into the antecubical (joint area between the upper and lower part of the arm) area of his right arm. There was no label on the tubing leading to the insertion site of IV into the skin of Patient 17.

During an interview on 4/11/2023 at 11:38 AM, RN 3 stated that it was important to date the catheter as it will remind staff to change it per hospital policy.

During a review of the document 'IV Therapy - Administration' (last revised 4/2016) this document specifies that central line (flexible tubing inserted into a larger vein, versus in the smaller veins of the hand and arm, to supply medicine or fluid to the patient) should be replaced weekly weekly and as needed; peripheral lines (those inserted into the arm or hand) should be changed every 72 hours. This document further explained that if inflammation or infection is noted in a peripheral line, the IV should be removed and reinserted in the opposite arm if possible.